Medicine for treating biofilm-associated bacterial infections and its uses

Abstract

The present invention relates to the use of apabicin in a method for treating bacterial infections associated with biofilms containing Staphylococcus bacteria, wherein the method comprises administering apabicin in combination with daptomycin and / or one or more additional agents selected from lipopeptides, glycopeptides, and lincosamides, or vancomycin to the patient.

Description

Technology Field

[0001] 1. Technology Field

[0002] The present invention relates to the treatment of bacterial infections. More specifically, the present invention provides means and methods for treating a bacterial infection in which bacteria are organized into a biofilm, preferably a biofilm containing or composed of Staphylococcus bacteria. To achieve a desired therapeutic effect, the present invention relies on a combination of apabicin and one or more additional antibiotics selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, or combinations thereof. Background Technology

[0003] 2. Background Technology

[0004] Bacteria can sometimes survive in the human body in an isolated form called a planktonic state. However, bacteria can also form biofilms; that is, communities of cell clusters typically attached to solid or external surfaces, such as dental materials, medical implants, or artificial joints. There is some degree of organization within biofilms, including the formation of water channels as a circulatory system for nutrient delivery and the removal of metabolic waste. Additionally, bacteria are generally embedded in an extracellular matrix composed of polysaccharides, proteins, teichoic acid, lipids, and extracellular DNA.

[0005] The human immune system is generally unable to successfully eradicate these biofilm-mediated infections, and since most antibiotics effective against airborne bacteria are ineffective against biofilm-mediated infections caused by the same bacteria, biofilm-associated bacterial infections are notoriously difficult to treat. This is believed to be caused by a combination of various defense mechanisms of biofilm-embedded bacteria, such as the following:

[0006] · The extracellular matrix prevents or hinders the access of drug substances to bacteria.

[0007] · At least some of the bacteria organized in biofilms are believed to be in a slow or non-growing state where extracellular material is hardly or not integrated into the cell.

[0008] · Biofilms are believed to contain various bacterial subpopulations with different levels of resistance; this increases the likelihood that at least some subpopulations of the biofilm will survive antibiotic drug attacks.

[0009] · Cells within biofilms may also rely on other defense mechanisms, such as the overexpression of specific genes and stress responses to hostile environmental conditions. These other defense mechanisms may also differ within different subpopulations of the biofilm.

[0010] Therefore, treatment options available for biofilm-mediated bacterial infections are currently very limited. The current standard of anti-biofilm therapy relies on rifampicin as a cornerstone. However, the use of rifampicin is limited due to its toxicity and patient intolerance. Furthermore, rifampicin monotherapy often induces bacterial resistance, rendering the regimen ineffective and potentially failing to provide patients with a suboptimal or treatment option. Additionally, the treatment of infections caused by rifampicin-resistant Staphylococcus necessitates a shift toward more complex and lengthy surgical strategies.

[0011] The rifampicin resistance rate of Staphylococcus varies by patient population and country. According to data from the European Committee on Antimicrobial Susceptibility Testing in 2016, the rate is 0.5–17%. However, in some countries, including Belarus, Montenegro, Serbia, and Turkey, the rifampicin resistance level of invasive S. aureus clinical isolates reached 14–24%. Furthermore, rifampicin intolerance and toxicity, along with resistance, can account for up to 25% of all acute staphylococcal prosthetic joint infections, and resistance to rifampicin in Staphylococcus epidermidis isolated from medical implant infections, more specifically prosthetic joint infections, can reach up to 39%.

[0012] Coagulase-negative staphylococci (CoNS), particularly S. epidermidis, the most common commensal on human epithelial surfaces, have emerged as important opportunistic pathogens. S. epidermidis is currently a major causative agent of catheter-related bloodstream infections and early-onset neonatal sepsis. It is also a frequent cause of biomedical device-related infections. The treatment challenges of these infections are becoming increasingly recognized, as the majority of hospital-acquired S. epidermidis infections can be multidrug-resistant (e.g., resistant to beta-lactams, fluoroquinolones, and rifampicin) and can be inherently chronic due to biofilm formation.

[0013] To reduce the risk of rifampicin resistance induction, particularly in the context of biofilm-mediated infections associated with medical implants, the standard of treatment relies on drug combinations including rifampicin and a second antibiotic. The second antibiotic is generally selected from nafcillin, oxacillin, cefazolin, vancomycin, daptomycin, linezolid, ciprofloxacin, levofloxacin, co-trimoxazole, minocycline, doxycycline, oral first-generation cephalosporins (e.g., cephalexin) or anti-staphylococcal penicillins (e.g., dicloxacillin), clindamycin, teicoplanin, or fusidic acid. However, because rifampicin and these second antibiotics are associated with specific toxicities, currently used combination therapy with rifampicin can lead to cumulative side effects.

[0014] Furthermore, the use of rifampicin is not recommended before, during, or after surgery if the wound remains wet, the drainage tube has not yet been removed, or other surgery is planned. This is because there is a risk of developing resistance to rifampicin in commensal bacteria, including Staphylococcus residing on the skin. Due to the proximity of open wounds and drainage, these rifampicin-resistant Staphylococcus can cause superinfection of medical implants. Delaying the use of rifampicin to minimize this risk may imply that initial patient care is suboptimal.

[0015] Given the increasing limitations of rifampicin described above, there is an urgent need to provide alternative treatments for biofilm-mediated infections that do not rely on rifampicin. Accordingly, the object of the present invention is to provide means and methods for treating biofilm-mediated bacterial infections, particularly biofilm-mediated infections associated with Staphylococcus bacteria, that do not rely on rifampicin as a drug substance.

[0016] Another object of the present invention is to provide means and methods for treating biofilm infections, preferably biofilm infections associated with Staphylococcus bacteria, which exhibit a cure rate of ≥ 20%, ≥ 25%, ≥ 30%, ≥ 35%, or ≥ 40% for infections associated with young (24-hour) biofilms, and a cure rate of ≥ 5%, ≥ 10%, or ≥ 15% for infections associated with old (72-hour) biofilms. Determining the cure rate of any means or method is within the scope of those skilled in the art. In particular, the cure rate may be determined using one or more of the models and techniques described in the embodiments included herein.

[0017] Another objective of the present invention is to provide means and methods for treating biofilm infections, preferably biofilm infections associated with Staphylococcus bacteria, which can be used (e.g., before and after surgery) in patients with moist wounds, inserted drainage, or planned surgery.

[0018] Another object of the present invention is to provide means and methods for treating biofilm infections and preferably biofilms associated with Staphylococcus bacteria, which can be used when rifampicin-based treatment is not feasible for reasons including but not limited to resistance or patient intolerance.

[0019] Additional objectives forming the basis of the present invention will become apparent from the detailed description provided below. Prior art literature

[65535] Japanese Patent Publication No. J.P. 2019-512467 (May 16, 2019) Japanese Patent Publication No. J.P. 2015-521617 (July 30, 2015) International Publication WO2006 / 130629 (April 23, 2009) "A FASII Inhibitor Prevents Staphylococcal Evasion of Daptomycin by Inhibiting Phospholipid Decoy Production", Antimicrobial Agents and Chemotherapy(2019), Vol. 63, Issue 4. e02105-18"In vitro activity (MICs and rate of kill) of AFN-1252, a novel FabI inhibitor, in the presence of serum and in combination with other antibiotics", Journal of Chemotherapy(2013), Vol. 25, No. 1, p18-25"Multiple Combination Bactericidal Testing of Staphylococcal Biofilms from Implant-Associated Infections", ANTIMICROBIAL AGENTS AND CHEMOTHERAPY (2006), Vol.50, No.1, pp55-61

[0020] 3. Summary of the Invention

[0021] The present invention achieves the above objective by providing a combination therapy for the treatment of biofilm-mediated bacterial infections, preferably biofilm infections associated with Staphylococcus bacteria, which relies on a combination of afabicin as an essential active pharmaceutical ingredient; and one or more additional antibiotics selected from the group consisting of lipopeptides, glycopeptides, and lincosamides. One or more additional agents are preferably selected from the group consisting of daptomycin, vancomycin, Surfactin, A54145, amfomycin, friulimicin, laspartomycin, WAP-8294A2, katanosin, Plusbacin A3, oritavancin, telavancin, teicoplanin, dalbavancin, ramoplanin, mannopeptimycin, clindamycin, lincomycin, and pirrimicin, and more preferably daptomycin and / or vancomycin and / or clindamycin. It is also possible to use combinations of two or more of these antibiotics with apabicin. For example, a combination of three antibiotics—apabicin, daptomycin, and vancomycin—or a combination of apabicin, daptomycin, and clindamycin, or a combination of apabicin, vancomycin, and clindamycin may be used. For simplicity, the following description of the invention collectively refers to these embodiments of the invention as "combinations of apabicin and one or more additional agents," etc.Accordingly, the present invention relates specifically to apabicin for use in combination with daptomycin and / or vancomycin and / or clindamycin for the treatment of biofilm-mediated infections and preferably Staphylococcus-containing biofilm-mediated infections. More specifically, the present invention relates to the following embodiments:

[0022] 1. Apabicin for use in a method for treating a bacterial infection associated with a biofilm, wherein the method comprises the step of administering the apabicin to a patient in combination with one or more additional agents selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, wherein the lipopeptide is preferably daptomycin, the glycopeptide is preferably vancomycin, and the lincosamide is preferably clindamycin.

[0023] 2. Apabicin in which the biofilm of Item 1 contains or is composed of Staphylococcus bacteria.

[0024] 3. In any one of items 1 to 2, the Staphylococcus bacteria are selected from the group consisting of the following:

[0025] - Staphylococcus aureus, including community-acquired Staphylococcus aureus and hospital-acquired Staphylococcus aureus

[0026] - Coagulase-negative Staphylococci (CoNS), e.g., Staphylococcus epidermidis, Staphylococcus haemolyticus, Staphylococcus lugdunensis, Staphylococcus simulans, Staphylococcus hominis, preferably CoNS is Staphylococcus epidermidis,

[0027] - Methicillin-susceptible or methicillin-resistant Staphylococcus, preferably Staphylococcus aureus or Staphylococcus epidermidis,

[0028] - As a Staphylococcus aureus strain or a CoNS strain, said strain is resistant to one or more antibiotics, preferably said antibiotic is selected from β-lactams, cephalosporins, glycopeptides such as vancomycin, lincosamides such as linezolid and clindamycin, lipopeptides such as rifampicin and daptomycin, fluoroquinolones, trimethoprim / sulfamethoxazole, phosphomycin, fusidic acid, tigecycline, tetracycline, and dalbavancin, and preferably the CoNS strain is Staphylococcus epidermidis.

[0029] - As a multidrug-resistant Staphylococcus strain, preferably the multidrug-resistant Staphylococcus strain is selected from the group consisting of multidrug-resistant Staphylococcus aureus strains and multidrug-resistant CoNS strains, and preferably the multidrug-resistant CoNS strain is Staphylococcus epidermidis;

[0030] Apabicin, preferably in which the Staphylococcus bacteria are Staphylococcus aureus and / or CoNS, and preferably the CoNS is Staphylococcus epidermidis.

[0031] 4. Apabicin, wherein in any one of items 1 to 3, the bacterial infection is associated with an open wound and / or a wet wound and / or a wound at a site with drainage, preferably the bacterial infection is associated with an open wound.

[0032] 5. Apabicin in combination with one or more additional agents in any one of items 1 to 4, wherein the apabicin is administered during the perioperative period and preferably before and / or after surgery.

[0033] 6. Apabicin, wherein in any one of items 1 to 5, the bacterial infection is associated with a biofilm containing Staphylococcus bacteria resistant to rifampicin.

[0034] 7. In any one of items 1 to 6, the bacterial infection is associated with a biofilm containing methicillin-resistant Staphylococcus aureus, preferably the Staphylococcus aureus is Staphylococcus aureus or CoNS, and preferably the CoNS is Staphylococcus epidermidis, apabicin.

[0035] 8. In any one of items 1 to 7, apabicin selected from the group consisting of the following, wherein the bacterial infection:

[0036] - Infections related to medical implants,

[0037] - Osteomyelitis,

[0038] - Infection in patients with cystic fibrosis,

[0039] - Pleuropulmonary infection, e.g., pneumonia, preferably the pleuropulmonary infection is chronic, more preferably the pleuropulmonary infection is an obstructive lung disease,

[0040] - Endocarditis, preferably native valve endocarditis,

[0041] - Wound infection, preferably chronic wound infection,

[0042] - Mastitis,

[0043] - Sinusitis, preferably chronic sinusitis,

[0044] - Otitis media, preferably chronic otitis media,

[0045] - Urinary tract infection,

[0046] - Tonsillitis, preferably the tonsillitis is chronic,

[0047] - Laryngitis, preferably chronic laryngitis,

[0048] - Infections associated with kidney stones,

[0049] - Biliary tract infection,

[0050] - Aerobic vaginitis,

[0051] - Septic thrombophlebitis,

[0052] - Infections associated with intracellular biofilms, e.g., infections associated with intracellular biofilms in Kupffer cells or amygdala cells, and

[0053] - Colonization by Staphylococcus aureus, which patients are susceptible to infection by.

[0054] 9. Apabicin, wherein in any one of items 1 to 8, the bacterial infection is a medical implant-associated infection, the medical implant is a permanent indwelling device, and preferably an artificial joint.

[0055] 10. Apabicin, wherein in any one of items 1 to 9, the bacterial infection is a medical implant-associated infection, preferably selected from catheter-associated infection, endotracheal tube-associated infection, voice prostheses-associated infection, and soft tissue filler-associated infection, and said soft tissue filler may be permanent or semi-permanent.

[0056] 11. Apabicin in any one of items 1 to 10, wherein the method comprises a debridement step in addition to the administration of apabicin combined with one or more additional agents.

[0057] 12. Apabicin according to items 8, 9, 10 or 11, wherein the method comprises the step of replacing a medical implant in addition to administering apabicin combined with one or more additional agents.

[0058] 13. In Item 12, the step of administering apabicin in combination with one or more additional agents is performed before and / or after the step of replacing the medical implant, and preferably said administration is performed before and after the step of replacing the medical implant.

[0059] 14. In any one of items 1 to 13, apabicin is administered intravenously, orally, parenterally and / or topically and / or transdermally.

[0060] 15. In any one of items 1 to 14, apabicin is administered intravenously in the first step and orally in the second step.

[0061] 16. Apabicin in any one of items 1 to 15, wherein one or more additional preparations are administered orally, parenterally, transdermally, intravenously, and / or topically.

[0062] 17. Apabicin according to item 12 or 13, wherein the method comprises a first step of removing a medical implant, a second step of administering apabicin intravenously in combination with one or more additional agents, a third step of introducing a new medical implant, a fourth step of administering apabicin intravenously in combination with one or more additional agents, and a fifth step of administering apabicin orally in combination with one or more additional agents.

[0063] 18. Apabicin, wherein in any one of items 1 to 17, one or more additional preparations are selected from the group consisting of daptomycin, vancomycin, surfactin, A54145, amfomycin, friulimicin, laspartomycin, WAP-8294A2, katanosin, plusbacin A3, oritavancin, telavancin, teicoplanin, dalbavancin, ramoplanin, mannopeptimycin, clindamycin, lincomycin, and pirrimicin.

[0064] 19. Apabicin, wherein one or more additional agents of Item 18 are daptomycin and / or vancomycin and / or clindamycin.

[0065] 20. Biofilm, preferably Staphylococcus ( staphylococcus Daptomycin for use in a method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the method is described in any one of items 1 to 19.

[0066] 21. Biofilm, preferably Staphylococcus ( staphylococcus Vancomycin for use in a method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the method is described in any one of items 1 to 19.

[0067] 22. Biofilm, preferably Staphylococcus ( staphylococcus Clindamycin for use in a method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the method is described in any one of items 1 to 19.

[0068] 23. Biofilm in patients requiring it, preferably Staphylococcus ( staphylococcus A method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the method is described in any one of items 1 to 19.

[0069] 24. Afabicin; and one or more additional agents selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, preferably one or more additional agents selected from the group consisting of daptomycin, vancomycin, surfactin, A54145, amfomycin, friulimicin, laspartomycin, WAP-8294A2, katanosin, plusbacin A3, oritavancin, telavancin, teicoplanin, dalbavancin, ramoplanin, mannopeptimycin, clindamycin, lincomycin, and pirlimicin. A biofilm, preferably Staphylococcus, comprising a preparation, more preferably daptomycin and / or vancomycin and / or clindamycin ( staphylococcus A pharmaceutical composition for use in a method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the method is described in any one of items 1 to 19.

[0070] 25. Afabicin; and one or more additional agents selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, preferably one or more additional agents selected from the group consisting of daptomycin, vancomycin, surfactin, A54145, amfomycin, friulimicin, laspartomycin, WAP-8294A2, katanosin, plusbacin A3, oritavancin, telavancin, teicoplanin, dalbavancin, ramoplanin, mannopeptimycin, clindamycin, lincomycin, and pirlimicin. A biofilm, preferably Staphylococcus, comprising a preparation, more preferably daptomycin and / or vancomycin and / or clindamycin ( staphylococcus A kit for use in a method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the method is described in any one of items 1 to 19.

[0071] In another more specific aspect, the present invention relates to the following:

[0072] 1. A method for using apabicin for treating a bacterial infection associated with a biofilm containing Staphylococcus bacteria, wherein the method comprises the step of administering apabicin to a patient in combination with daptomycin and / or vancomycin.

[0073] 2. In Item 1, Staphylococcus bacteria are selected from the group consisting of the following:

[0074] - Staphylococcus aureus, including community-acquired Staphylococcus aureus and hospital-acquired Staphylococcus aureus

[0075] - Coagulase-negative Staphylococci (CoNS), e.g., Staphylococcus epidermidis, Staphylococcus haemolyticus, Staphylococcus lugdunensis, Staphylococcus simulans, Staphylococcus hominis, preferably CoNS is Staphylococcus epidermidis,

[0076] - Methicillin-susceptible or methicillin-resistant Staphylococcus, preferably Staphylococcus aureus or Staphylococcus epidermidis,

[0077] - A Staphylococcus aureus strain or a CoNS strain, wherein the strain is resistant to one or more antibiotics, preferably the antibiotic is selected from β-lactam, cephalosporin, vancomycin, linezolid, clindamycin, rifampicin, daptomycin, fluoroquinolone, trimethoprim / sulfamethoxazole, phosphomycin, fusidic acid, tigecycline, tetracycline, and dalbavancin, and preferably the CoNS strain is Staphylococcus epidermidis.

[0078] - As a multidrug-resistant Staphylococcus strain, preferably the multidrug-resistant Staphylococcus strain is selected from the group consisting of multidrug-resistant Staphylococcus aureus strains and multidrug-resistant CoNS strains, and preferably the multidrug-resistant CoNS strain is Staphylococcus epidermidis.

[0079] Apabicin, preferably in which the Staphylococcus bacteria are Staphylococcus aureus and / or CoNS, and preferably the CoNS is Staphylococcus epidermidis.

[0080] 3. Apabicin according to Item 1 or 2, wherein the bacterial infection is associated with an open wound and / or a wet wound and / or a wound with drainage, preferably the bacterial infection is associated with an open wound.

[0081] 4. Apabicin in combination with daptomycin and / or vancomycin in any one of items 1 to 3, administered during the perioperative period and preferably before and / or after surgery.

[0082] 5. Apabicin, wherein in any one of items 1 to 4, the bacterial infection is associated with a biofilm containing Staphylococcus bacteria resistant to rifampicin.

[0083] 6. In any one of items 1 to 5, the bacterial infection is associated with a biofilm containing methicillin-resistant Staphylococcus aureus, preferably the Staphylococcus aureus is Staphylococcus aureus or CoNS, and preferably the CoNS is Staphylococcus epidermidis, apabicin.

[0084] 7. In any one of items 1 to 6, apabicin selected from the group consisting of the following, wherein the bacterial infection is infected:

[0085] - Infections related to medical implants,

[0086] - Osteomyelitis,

[0087] - Infection in patients with cystic fibrosis,

[0088] - Pleuropulmonary infection, e.g., pneumonia, preferably the pleuropulmonary infection is chronic, more preferably the pleuropulmonary infection is an obstructive lung disease,

[0089] - Endocarditis, preferably native valve endocarditis,

[0090] - Wound infection, preferably chronic wound infection,

[0091] - Mastitis,

[0092] - Sinusitis, preferably chronic sinusitis,

[0093] - Otitis media, preferably chronic otitis media,

[0094] - Urinary tract infection,

[0095] - Tonsillitis, preferably the tonsillitis is chronic,

[0096] - Laryngitis, preferably chronic laryngitis,

[0097] - Infections associated with kidney stones,

[0098] - Biliary tract infection,

[0099] - Aerobic vaginitis,

[0100] - Septic thrombophlebitis,

[0101] - Infections associated with intracellular biofilms, e.g., infections associated with intracellular biofilms in Kupffer cells or amygdala cells, and

[0102] - Colonization by Staphylococcus aureus, which patients are susceptible to infection by.

[0103] 8. In any one of items 1 to 7, the bacterial infection is a medical implant-associated infection, the medical implant is a permanent indwelling device, and preferably an artificial joint, apabicin.

[0104] 9. Apabicin, wherein in any one of items 1 to 8, the bacterial infection is a medical implant-associated infection, preferably selected from catheter-associated infection, endotracheal tube-associated infection, voice prostheses-associated infection, and soft tissue filler-associated infection, and said soft tissue filler may be permanent or semi-permanent.

[0105] 10. Apabicin in any one of items 1 to 9, wherein the method comprises a debridement step in addition to the administration of apabicin combined with daptomycin and / or vancomycin.

[0106] 11. Apabicin according to item 7, 8, 9 or 10, wherein the method comprises the step of replacing a medical implant in addition to administering apabicin combined with daptomycin and / or vancomycin.

[0107] 12. In Item 11, the step of administering apabicin in combination with daptomycin and / or vancomycin is performed before and / or after the step of replacing the medical implant, and preferably said administration is performed before and after the step of replacing the medical implant.

[0108] 13. In any one of items 1 to 11, apabicin is administered intravenously, orally, parenterally and / or topically and / or transdermally.

[0109] 14. In any one of items 1 to 13, apabicin is administered intravenously in the first step and orally in the second step.

[0110] 15. Apabicin, wherein in any one of items 1 to 14, daptomycin and / or vancomycin are administered intravenously and / or topically.

[0111] 16. Apabicin according to Item 11 or 12, wherein the method comprises: a first step of removing a medical implant; a second step of administering apabicin intravenously in combination with daptomycin and / or vancomycin; a third step of introducing a new medical implant; a fourth step of administering apabicin intravenously in combination with daptomycin and / or vancomycin; and a fifth step of administering apabicin orally in combination with daptomycin and / or vancomycin.

[0112] 17. Staphylococcus ( staphylococcus Daptomycin for use in a method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the method is described in any one of items 1 to 16.

[0113] 18. Staphylococcus ( staphylococcus Vancomycin for use in a method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the method is described in any one of items 1 to 16.

[0114] 19. Staphylococcus in patients requiring it ( staphylococcus A method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the method is described in any one of items 1 to 16.

[0115] Further embodiments of the present invention become apparent from the detailed description of the present invention provided below. Brief explanation of the drawing

[0116] 4. Description of the Drawing Figure 1 is a schematic diagram illustrating treatment options for medical implant infections, more specifically artificial joint infections, based on various scenarios. Figure 2 is a schematic diagram illustrating treatment options for medical implant infections, more specifically artificial joint infections, based on various scenarios. Figure 3 shows the effect of 5.5-day antibiotic treatment on biofilm-embedded bacteria in a mouse tissue cage model. The adherent bacterial fraction was determined by plating a medium after sonication of the transplanted tissue cages from untreated control animals infected 24 hours after infection (baseline, before treatment) and from antibiotic-treated and vehicle-treated animals on day 9. The cure rate was indicated. Statistical analysis of the comparison between the vehicle group and the treatment group was performed using Dunn's multiple comparison test following the nonparametric Kruskal-Wallis test (** p<0.005); ns = not significant. Figure 4 shows the effect of 11-day antibiotic treatment on biofilm-gut bacteria in a mouse tissue cage model. The adherent bacterial fraction was determined by plating a medium after sonication of transplanted tissue cages from infected untreated control animals at 24 hours post-infection (baseline, before treatment) and from antibiotic-treated and vehicle-treated animals at day 14. Cure rates were indicated. Statistical analysis of the comparison between the vehicle group and the treatment group was performed using Dunn's multiple comparison test following the nonparametric Kruskal-Wallis test (** p<0.005); ns = not significant. Specific details for implementing the invention

[0117] 5. Detailed Description of the Invention

[0118] 5.1. Definition

[0119] The following definitions are provided to assist the reader. Unless otherwise defined, all terms, notations, other scientific or medical terms, or technical terms used herein are intended to have the meaning commonly understood by those skilled in the art of chemistry and medicine. In some cases, terms having the commonly understood meaning are defined herein for clarity and / or ease of reference, and the inclusion of such definitions herein should not be interpreted as representing a substantial difference from the definitions of terms generally understood in the art. Where ambiguous, the definitions and information contained in WO 2013 / 190384 A should be used auxiliaryly and to the extent consistent with the present invention. As supplementary sources of information, dictionaries of chemistry, pharmacy and medicine, in particular Rφmpp "Lexikon Chemie", Thieme Verlag 1999; Remington "The Science and Practice of Pharmacy", Pharmaceutical Press, 2012; and "Stedman's Medical Dictionary", Wolters Kluwer, 2006 are used as additional supplementary sources of information, but only to the extent consistent with the information provided in this and WO 2013 / 190384 A. Unless otherwise stated, references to Internet pages should be understood as references to each page of the version as of June 14, 2019.

[0120] Unless otherwise indicated by the context, the term "indefinite article" (“a” or “an”) specifies a substance or component, but does not limit the number or amount. For example, the term "binder" should be understood to refer to a single binder, or alternatively, a combination of two or more binders. The same applies even when no article is used. For example, "infection associated with biofilm" may be associated with one, two, or more distinct biofilm colonies.

[0121] In some embodiments, the term “about” refers to a deviation of ± 10% from the quoted value. It should be understood that when the word “about” is used herein in relation to a number, another embodiment of the invention includes a number that is not modified by the presence of the word “about”.

[0122] "Administration" of a drug to a patient or "administering" a drug (and grammatical equivalents of this phrase) refers to direct administration, which may be administered by a medical professional to the patient or self-administration, and / or indirect administration, which may be the act of prescribing the drug. For example, an attending physician instructing a patient to self-administer a drug or providing the patient with a prescription for a drug constitutes administering the drug to the patient.

[0123] In the context of the present invention, the term “biofilm” is used to refer to a structured aggregate of one or more species of microbial cells wrapped in a self-produced matrix and attached to a biological or non-biological surface. In the context of the present invention, the term “biofilm” is also used to refer to a structured aggregate of microbial cells as defined above, but separated from a biological or non-biological surface by denecrosis and / or other physical and / or surgical methods.

[0124] The term “combination product” refers to (i’) a product composed of two or more controlled components that are combined or mixed by physical, chemical, or other means to produce a single entity; (ii’) two or more individual products that are packaged together in a single package or as a single unit and consist of a drug and medical device product, a medical device and a biological product, or a biological and a pharmaceutical product; and (iii’) a separately packaged drug, medical device, or biological product intended solely for use with a specific drug, medical device, or biological product that is individually approved, in accordance with the study plan or proposed labeling (both of which are necessary to achieve the intended use, indication, or effect, and upon approval of the proposed product, the labeling of the approved product must be changed to reflect, for example, a significant change in the intended use, formulation, concentration, route of administration, or dose); or (iv') any separately packaged investigational drug, medical device, or biological product intended solely for use in conjunction with other individual specific investigational drugs, medical devices, or biological products as per the proposed labeling (both of which are necessary to achieve the intended use, indication, or effect).

[0125] As used herein, “combination therapy,” “in combination with,” or “in conjunction with” refers to any form of concomitant, parallel, simultaneous, sequential, or intermittent treatment using two or more distinct modes of treatment (i.e., compounds, components, targeted agents, or therapeutic agents). Accordingly, this term refers to the administration of one mode of treatment to an individual prior to, during, or after the administration of one mode of treatment. The combined modes may be administered in any order. The therapeutically active modes may be administered together (e.g., simultaneously in the same or separate compositions, formulations, or unit dosage forms) or separately (e.g., on the same or different days, and in any order according to appropriate administration protocols for separate compositions, formulations, or unit dosage forms) in the manner and regimen prescribed by a healthcare professional or regulatory authority. Generally, each mode of treatment will be administered according to the dose and / or schedule determined for that mode of treatment. Optionally, three or more modes may be used in combination therapy. Additionally, the combination therapy provided herein may be used in combination with other types of treatment. For example, other antibiotics may be administered additionally.

[0126] The verbs "include" and "contain" present an indefinite list that allows for the additional presence of additional components not included in the list. In contrast, the verb "consists of" presents a limited list that does not allow for the additional presence of unmentioned additional components. When the verbs "include" or "contain" are used in this application, it implies encompassing the option "consists of" as a preferred embodiment.

[0127] This application refers to a “component” of the pharmaceutical composition of the present invention as any substance present in a final product that includes an excipient and also includes a pharmaceutically active ingredient. The term “component” also includes a tablet coating (if present) or a capsule shell (if present). An “excipient” is any component of the pharmaceutical composition that does not exhibit a pharmaceutical effect on its own, i.e., any component other than the pharmaceutically active ingredient.

[0128] Infections are "difficult to treat" when they involve biofilms formed by microorganisms that are difficult to treat. These are microorganisms that are resistant to antibiotics, particularly rifampicin-resistant staphylococci, enterococci, and quinolone-resistant Gram-negative bacilli and fungi.

[0129] "Dosage" and "administrative amount" refer to specific amounts of active agent or therapeutic agent for administration. These amounts are included in "administrative forms," ​​which refer to physically distinct units suitable as a single dose for human individuals and other mammals, each of which contains a predetermined amount of active agent calculated to produce the desired onset, tolerability, and therapeutic effect, together with one or more suitable pharmaceutical excipients such as a carrier.

[0130] The terms “individual,” “patient,” or “entity” are used interchangeably in this application and are not intended to be restrictive in any way. An “individual,” “patient,” or “entity” may have any age, gender, and physical condition. Preferably, the therapeutic methods and combinations of the present invention are intended for use on human patients. That is, the individual, patient, or entity is preferably a human. Any reference to “individual,” “patient,” or “entity” in this specification should also be understood as a reference to a human “human individual,” “human patient,” or “human entity.”

[0131] Terms such as "infections involving biofilm" and "biofilm-associated infections" are used herein to characterize bacterial infections in which bacteria have formed a biofilm. It is not always clear whether a biofilm has actually formed, for example, because this fact cannot be proven due to the patient's pathological condition. In such situations, the combination therapy of the present invention may be used. This can be viewed as a prophylactic treatment to prevent biofilm formation. Likewise, all references herein to infections that may or may not have a biofilm are intended to refer to each infection in which a biofilm has formed or may have formed.

[0132] "Infusion" or "infusing" refers to the introduction of a drug-containing solution into the body via a vein for therapeutic purposes. Generally, this is achieved through an intravenous bag.

[0133] In the context of the present invention, "pharmaceuticalally acceptable" is used to refer to compounds, substances, compositions, and / or dosage forms suitable for use in contact with human and animal tissues without excessive toxicity, irritation, allergic reactions, and / or other problems or complications, corresponding to a reasonable benefit / risk ratio within the scope of reasonable medical judgment.

[0134] As used herein, “pharmaceuticalally acceptable carriers” or “pharmaceuticalally acceptable diluents” means any solvent, dispersion medium, coating, antimicrobial and antifungal agent, isotonic agent, and absorption retardant suitable for pharmaceutical administration. The use of such media and formulations for pharmaceutically active substances is well known in the art. Acceptable carriers, excipients, or stabilizers are non-toxic to the recipient at the dosage and concentration used and, without limiting the scope of the invention, include: additional buffers; preservatives; cosolvents; antioxidants including ascorbic acid and methionine; chelating agents such as EDTA; metal complexes (e.g., Zn-protein complexes); biodegradable polymers such as polyesters; salt-forming counterions such as sodium and polysaccharide alcohols; amino acids such as alanine, glycine, glutamine, asparagine, histidine, arginine, lysine, ornithine, leucine, 2-phenylalanine, glutamic acid, and threonine; Organic sugars or sugar alcohols such as lactitol, stachyose, mannose, sorbose, xylose, ribose, ribitol, myoinisitose, myoinisitol, galactose, galactitol, glycerol, cyclitol (e.g., inositol), and polyethylene glycol; sulfur-containing reducing agents such as urea, glutathione, thioctic acid, sodium thioglycolate, thioglycerol, α-monothioglycerol, and sodium thiosulfate; low molecular weight proteins such as human serum albumin, bovine serum albumin, gelatin, or other immunoglobulins; and hydrophilic polymers such as polyvinylpyrrolidone. Other pharmaceutically acceptable carriers, excipients, or diluents, e.g., Remington's Pharmaceutical Sciences 16th edition, Osol, A. Ed. The elements described in (1980) may also be included in the pharmaceutical composition described herein, provided that they do not adversely affect the desired features of the pharmaceutical composition.

[0135] "Pharmaceuticalally acceptable salt" is used in the context of the present invention to characterize any form of ionic species of a drug (acid addition salt, base addition salt, zwitterionic / internal salt, etc.) that is pharmaceutically acceptable as defined above. Unless otherwise specified, all references to pharmaceutically active compounds in this application shall be understood as references to each compound in its free form, and also to the pharmaceutically acceptable salt of each compound.

[0136] The term “therapeutic effective dose” refers to an amount of the active ingredient (drug substance) and, for example, an amount of one or more additional agents selected from the group consisting of apabicin and / or lipopeptides, glycopeptides, and lincosamides, which have a therapeutic effect and are capable of treating biofilm-associated Staphylococcus infection in particular. The therapeutic effective dose of the drug achieves: reducing the number of bacterial cells; reducing the size or burden of the biofilm; inhibiting bacterial cell infiltration into peripheral organs (i.e., slowing it to some extent and stopping it in certain embodiments); inhibiting biofilm growth (i.e., slowing it to some extent and stopping it in certain embodiments); alleviating one or more symptoms associated with the infection to some extent; or achieving any combination thereof. “Prophylactic effective dose” refers to an effective amount for the required dosage and duration to achieve the desired prophylactic outcome in a patient at risk of biofilm-associated Staphylococcus infection. Although not always the case, since prophylactic doses are generally used in individuals prior to or in the early stages of the disease, the prophylactic effective dose will be lower than the therapeutic effective dose. Nevertheless, the therapeutic effective dose is also the prophylactic effective dose.

[0137] As used in this application, the terms “treatment” and “therapy” refer to a set of hygienic, pharmacological, surgical, and / or physical means used with the intent to treat and / or alleviate diseases and / or symptoms with the aim of improving health problems. The terms “treatment” and “therapy” include preventive and curative methods, as both relate to the maintenance and / or re-establishment of health in individuals or animals. Regardless of the origin of symptoms, diseases, and disorders, the administration of appropriate medicines to alleviate and / or treat health problems should be interpreted as a form of treatment or therapy within the context of this application.

[0138] As used herein, "unit dosage form" refers to physically distinct units of a therapeutic formulation appropriate for the subject being treated. However, it will be understood that the total daily use of the composition of the present invention will be determined by the attending physician within the scope of reasonable medical judgment. The specific effective dose level for any specific individual or organism will depend on various factors including the disorder being treated and the severity of the disorder; the activity of the specific active agent used; the specific composition used; the age, weight, general health, sex, and diet of the individual; the time of administration and the elimination rate of the specific active agent used; the duration of treatment; drugs and / or additional therapies used in combination with or simultaneously with the specific compound(s) used; and similar factors well known in the medical field.

[0139] As used herein, the term "medical implant" refers to any indwelling medical device (placed inside a patient's body) intended to replace, support, or enhance a biological structure. Medical implants, such as stents or artificial joints, may be permanently implanted, or alternatively, such as chemotherapy ports or orthopedic screws, may be temporarily implanted and removed when no longer needed.

[0140] Non-limiting examples of medical implants include stents, shunts, e.g., ventricular shunts, ventricular assist devices, vascular grafts, vascular clips, artificial joints, cardiac defibrillators (defibrillators), pacemakers, artificial joints, e.g., artificial hip and knee joints, artificial heart valves, breast implants, orthopedic screws, orthopedic rods, orthopedic plates, artificial spinal discs, intrauterine devices (IUDs), coronary stents, ear tubes, intraocular lenses, contact lenses, catheters, e.g., central venous catheters, peripheral vascular catheters, peritoneal dialysis catheters, urethral catheters, endotracheal tubes, artificial larynges, and soft tissue fillers (permanent or semi-permanent tissue fillers).

[0141] As used herein, the term "antibiotic implant" refers to any indwelling medical device (placed inside a patient's body) that is implanted in a patient with the primary intent of treating or preventing an infection, e.g., a bacterial infection through the delivery of antibiotics. The antibiotic implant may be permanently implanted, temporarily implanted and removed when no longer needed, e.g. when the infection has been eradicated, or simply dissolved within the body over time.

[0142] Non-limiting examples of antibiotic implants include antibiotic-loaded beads or spacers.

[0143] The present invention relates to a pharmaceutical composition containing a combination, combination, or drug combination of apabicin and one or more additional agents selected from the group consisting of lipopeptides, glycopeptides, and lincosamides for use in combination therapy; a kit containing such drug combination in a separate container; a composition containing one of these drugs for use in combination with each other drug (and vice versa); as well as a therapeutic method comprising administering one or more of these products. Unless the context otherwise indicates, any reference to any of the above-mentioned aspects of the present invention should also be understood as a reference to other aspects of the present invention listed above. For example, a reference to the method of the present invention should also be understood as a disclosure of the pharmaceutical composition of the present invention used in such a method. Likewise, a reference to the pharmaceutical composition of the present invention should also be understood as a disclosure of the method of the present invention using such pharmaceutical composition.

[0144] Unless otherwise specified, all absolute quantity indications in this application are provided in mg. Unless otherwise specified, all relative quantity indications are provided in weight % (wt%) based on the total weight of the pharmaceutical composition. If the pharmaceutical composition is in the form of a coated tablet, the weight of the coating is not included in the total weight. If the pharmaceutical composition is in the form of a capsule, the weight of the capsule shell is also excluded from the total weight. The weight of any liquid that may be temporarily present during wet granulation but is removed by a subsequent drying procedure is not included in the total weight.

[0145] Unless otherwise specified, all absolute amount indications of the active substance apabicin (e.g., daily dose) are based on the molecular weight of the free acid form. Therefore, when using the salt form of apabicin, the specified absolute amount must be converted by taking into account the relative molecular weight. This can be done using the following equation (1).

[0146] m(salt) = m(free acid)*M(salt) / M(free acid) (1)

[0147] In the above formula, m represents the absolute amount, and M represents the molecular weight of each form.

[0148] Unless otherwise specified, all relative quantity indications, for example, the composition range of the active substance afabicin, are based on the molecular weight of the bis-ethanolamine salt of afabicin (Afabicin Olamine). Therefore, when using other salt forms or free acid forms of afabicin, the specified absolute quantity must be converted by taking into account the relative molecular weight. This can be done using the following equation (2).

[0149] w(s2) = 100*w(s1)*M(s2) / (M(s1)*(100+w(s1)*(M(s2)-M(s1)) / M(s1))) (2)

[0150] In the above formula, w(s2) is the relative amount of the second salt form or free acid form (weight%) based on the total weight of the composition containing this salt form; w(s1) is the relative amount of the bis-ethanolamine salt form (weight%) based on the total weight of the composition containing the bis-ethanolamine salt form; M(s2) is the molecular weight of the second salt form or free acid form; and M(s1) is the molecular weight of the bis-ethanolamine salt form.

[0151] In this application, any indication that the pharmaceutical composition of the present invention is "fee" of a specific substance, that such a substance is not present, or that said substance is absent or omitted should be understood as meaning that the relative amount of said substance in the pharmaceutical composition is less than 0.1 wt%, preferably less than 0.01 wt%. According to a particularly preferred embodiment, said substance is present in such small a quantity that it cannot be detected based on the analytical techniques available at the filing date, or is completely absent. According to another embodiment, the pharmaceutical composition contains each substance in such small a quantity that there is no measurable effect on the solubility characteristics of the active ingredient apabicin.

[0152] Although the present invention is described below primarily by describing “specific embodiments” of the invention (or by using similar terms such as “any embodiments,” etc.), such disclosure of multiple embodiments should also be understood as disclosure of each combination of features unless otherwise indicated by the context.

[0153] 5.2. Overview

[0154] Infections associated with biofilms are very difficult to treat, and antibiotics that are therapeutically active against specific airborne bacteria often fail to exhibit therapeutic activity when the same bacteria exist in the form of a biofilm. For this reason, there are very few effective treatments for biofilm-associated infections.

[0155] Although apabicin is known to be effective in treating airborne Staphylococcus infections, it is unknown whether it is also effective in treating biofilm-associated infections involving Staphylococcus bacteria. In preliminary studies, apabicin was shown to exhibit only moderate anti-biofilm activity when used as monotherapy. The same is true for many other antibiotics, including daptomycin and / or vancomycin.

[0156] The present invention is based on the surprising discovery that when apabicin is combined with one or more additional antibiotics selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, an effective treatment of biofilm infections, more specifically biofilm infections associated with Staphylococcus bacteria, can be provided. Preferably, said one or more additional agents are selected from the group consisting of daptomycin, vancomycin, surfactin, A54145, amfomycin, priulimicin, raspartomycin, WAP-8294A2, catanosine, plusvacin A3, oritavancin, telavancin, teicoplanin, dalbavancin, ramoplanin, mannopeptimicin, clindamycin, lincomycin, and pyrlimycin, and more preferably daptomycin and / or vancomycin and / or clindamycin. In all embodiments of the present invention, these agents may be used in free form or in pharmaceutically acceptable salt form. Similarly, there are no specific restrictions regarding the possible use of hydrates, solvates, and / or polymorphs of any of these formulations. Accordingly, references to apabicin and / or any of the aforementioned additional formulations should be understood to also include references to their respective pharmaceutically acceptable salts, hydrates, solvates, and polymorphs. Accordingly, the present invention provides a treatment for biofilm infections, preferably biofilm infections associated with Staphylococcus bacteria, comprising the use of apabicin and one or more additional antibiotics selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, e.g., preferably the formulations listed above, and more preferably a combination of daptomycin and / or vancomycin and / or clindamycin. This includes providing apabicin for use in combination with one or more additional antibiotics selected from the group consisting of lipopeptides, glycopeptides, and lincosamides in the treatment of biofilm infections, preferably biofilm infections associated with Staphylococcus bacteria.This also includes providing daptomycin and / or vancomycin and / or clindamycin for use in combination with apabicin in the treatment of biofilm infections and preferably biofilm infections associated with Staphylococcus bacteria; this also includes providing a combination of apabicin and one or more additional antibiotics selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, for example, preferably the agents listed above, and more preferably daptomycin and / or vancomycin and / or clindamycin, in the treatment of biofilm infections and preferably biofilm infections associated with Staphylococcus bacteria. This also includes a method for treating biofilm infections and preferably biofilm infections associated with Staphylococcus bacteria in a patient requiring this, comprising the administration of apabicin in combination with the administration of one or more additional antibiotics selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, for example, preferably the agents listed above, and more preferably daptomycin and / or vancomycin and / or clindamycin.

[0157] Apabicin and one or more additional agents may or may not be present in the same composition. Two or more drugs may be administered in the form of different pharmaceutical compositions, by different routes of administration, at different times of administration, and at different intervals of administration, etc.

[0158] 5.3. Apabicin

[0159] The INN name of apabicin is {6-[(1 E )-3-{methyl[(3-methyl-1-benzofuran-2-yl)methyl]amino}-3-oxoprop-1-en-1-yl]-2-oxo-3,4-dihydro-1,8-naphthiridine-1(2 HIt is )-yl}methyl dihydrogen phosphate. Other names for this compound are ((E)-6-[(N-methyl-((3-methylbenzofuran-2-yl)methyl)amino)-3-oxoprop-1-en-1-yl)-2-oxo-3,4-dihydro-1,8-naphthiridine-1(2H)-yl]methyl phosphate and (2E)-2-propenamide, N-methyl-N-[(3-methyl-2-benzofuranyl)methyl]-3-[5,6,7,8-tetrahydro-7-oxo-8-[(phosphonooxy)methyl]-1,8-naphthiridine-3-yl]. It is sometimes called Debio 1450. It is a Staphylococcus-selective antibiotic that acts as a FabI inhibitor. It is noteworthy that apabicin exhibits activity against Staphylococcus strains resistant to antibiotics such as β-lactams, vancomycin, daptomycin, and linezolid. Apabicin is also active against methicillin-resistant Staphylococcus aureus (MRSA). The structure of apabicin is as follows:

[0160]

[0161] The free acid form of apabicin originates from the following CAS RN 1518800-35-5.

[0162] Apabicin (Debio 1450) is described specifically in WO 2013 / 190 384. Specific uses of apabicin in the treatment of diabetic foot infections are described in WO 2017 / 144 717. The disclosures of these earlier applications are incorporated herein by reference in their entirety.

[0163] All references to apabicin in this application should be understood as referring to apabicin in the free acid form described above, or alternatively, to pharmaceutically acceptable salts of apabicin. Preferred embodiments relate to the use of the bis-ethanol ammonium salt of apabicin or BES (sometimes referred to as apabicin olamin, bis-ethanolamine salt of apabicin, or Debio 1450 BES). CAS RN 1518800-36-6 is derived from this bis-ethanolamine salt. A mixture of the free acid form of apabicin and the bis-ethanolamine salt is also advantageously used. According to a particularly preferred embodiment of this application, all references to apabicin should be understood as referring to the apabicin bis-ethanolamine salt in combination with apabicin in the free acid form. In the most preferred embodiment, a combination of apabicin in the free acid form and apabicin bis-ethanolamine salt is used, and the molar ratio of free acid to bis-ethanolamine salt is 0.7 to 0.9, more preferably 0.75 to 0.85.

[0164] Apabicin is a prodrug. The pharmaceutically active metabolite is (E)-N-methyl-N-((3-methylbenzofuran-2-yl)methyl)-3-(7-oxo-5,6,7,8-tetrahydro-1,8-naphthiridine-3-yl)acrylamide, also known as Debio 1452 (sometimes referred to as AFN-1252), and its CAS RN is 620175-39-5. It has the following structure:

[0165]

[0166] According to another embodiment of the present invention, it is possible to use the parent compound Debio 1452 or a pharmaceutically acceptable salt thereof instead of the prodrug compound. According to this embodiment, references to the use of apabicin should be understood as references to Debio 1452, provided that Debio 1452 is more limited in terms of feasible dosage forms.

[0167] 5.4. Daptomycin

[0168] Daptomycin is a naturally occurring lipopeptide with the following structure:

[0169]

[0170] Daptomycin is marketed by Novartis in the EU and by Cubist Pharmaceuticals in the US. It works by incorporating into the bacterial cell membrane to create pores, leading to depolarization and ultimately the death of the bacterial cell. It is typically administered via intravenous injection or infusion. It is sold under the brand name Cubicin®. Detailed information on its actual application can be found in the product characteristics summary published by the European Medicines Agency. https: / / www.ema.europa.eu / en / documents / product-information / cubicin-epar-product-information_en.pdf.

[0171] 5.5. Vancomycin

[0172] Vancomycin is a glycopeptide antibiotic. It has the following structure:

[0173]

[0174] Vancomycin was developed by Eli Lilly. It is available, in particular, under the brand name Vancocin®. It works by incorporating into the cell membrane of Gram-positive bacteria, causing the membrane to weaken and ultimately be destroyed due to osmotic pressure. It is typically administered by intravenous injection. Further details regarding its use can be found in the Wikipedia article "Vancomycin" (version 17, 2019), the references cited herein, and, in particular, the publicly available product characteristics summary found at https: / / www.medicines.org.uk / emc / product / 6255 / smpc#PRODUCTINFO.

[0175] 5.6. Clindamycin

[0176] Clindamycin acts as an inhibitor of bacterial protein synthesis by inhibiting ribosomal translocation. It has the following chemical structure:

[0177]

[0178] Clindamycin belongs to the lincosamide antibiotic group. It can be administered orally (in capsule or tablet form), topically (cream or gel), or parenterally (IV infusion or IM or SC injection). It is commercially available under the brand names Sobelin® and Cleocin®. Generic versions of this drug are available. Further information on clindamycin can be found in the Wikipedia article "Clindamycin" (version June 5, 2020) and in the references cited herein. Detailed information on its use can be found at https: / / www.drugs.com / clindamycin.html and in the publicly available product characteristics summary, which can be found specifically at https: / / www.medicines.org.uk / emc / medicine / 29227 for the infusion and https: / / www.medicines.org.uk / emc / product / 7337 / smpc for the capsule.

[0179] 5.7. Other Preparations

[0180] One or more additional agents may also be other agents belonging to the group of lipopeptides, glycopeptides, and lincosamides. Members of this group are, in particular, Surpactin, A54145, Amfomycin, Priulimicin, Raspartomycin, WAP-8294A2, Catanosine, Plusvacin A3, Oritavancin, Telavancin, Teicoplanin, Dalbavancin, Ramoplanin, Mannopeptimicin, Lincomycin, and Pyrlimycin.

[0181] Information on lipopeptides can be found in, for example, RH@@@Baltz et al., Nat Prod Rep., 2005 Dec;22(6):717-41. doi: 10.1039 / b416648p. Epub 2005 Nov 4 (accessible via https: / / www.ncbi.nlm.nih.gov / pubmed / 16311632) and the literature cited herein.

[0182] Information on glycopeptides can be found, for example, in S. Li and ES Starkey Arch Dis Child Educ Pract Ed. 2016 Dec;101(6):323-326. doi: 10.1136 / archdischild-2015-309270. Epub 2016 Jul 7 (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 27389546 / ) and in the literature cited herein.

[0183] Information on lincosamide can be found, for example, in J. Spνzek and T. Rezanka Biochem Pharmacol. 2017 Jun 1;133:20-28. doi: 10.1016 / j.bcp.2016.12.001. Epub 2016 Dec 7 (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 27389546 / ) and in the literature cited herein.

[0184] Information on surfactin can be found in the relevant Wikipedia entry (as of June 10, 2020), R. Sen, Adv Exp Med Biol. 2010;672:316-23. doi: 10.1007 / 978-1-4419-5979-9_24 (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 27940264 / ), and the literature cited here.

[0185] Information on A54145 can be found in DS Fukuda et al., J Antibiot (Tokyo), 1990 Jun;43(6):601-6. doi: 10.7164 / antibiotics.43.601 (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 2380108 / ) and in the literature cited here.

[0186] Information on amfomycin can be found in M. Singh et al., Scientific Reports | 6:31757 | DOI: 10.1038 / srep31757 (accessible via https: / / www.nature.com / articles / srep31757.pdf) and in the literature cited herein.

[0187] Information on Friulimicin can be found in the relevant Wikipedia entry (as of June 10, 2020), T. Schneider et al., Antimicrob Agents Chemother. 2009 Apr;53(4):1610-8. doi: 10.1128 / AAC.01040-08. Epub 2009 Jan 21 (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 19164139 / ), and the literature cited here.

[0188] Information on raspartomycin can be found in DB Borders et al., Nat. Prod. 2007, 70, 3, 443-446 (accessible via https: / / pubs.acs.org / doi / 10.1021 / np068056f) and the literature cited herein.

[0189] Information on WAP-8294A2 can be found in A. Kato et al. in The Journal of Antibiotics, 64, 373-379, 2011 (accessible via https: / / www.nature.com / articles / ja20119) and in the literature cited herein.

[0190] Information on catabosine can be found in the relevant Wikipedia entry (as of June 10, 2020), H. Maki et al. Antimicrob Agents Chemother. 2001 Jun;45(6):1823-7. doi: 10.1128 / AAC.45.6.1823-1827.2001 (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 11353632 / ), and the literature cited therein. This latter paper also provides information on plusbasin A3.

[0191] Information on the oritabane can be found in the relevant Wikipedia entry (as of June 10, 2020), J. Mattox et al. Consult Pharm. 2016 Feb;31(2):86-95. doi: 10.4140 / TCP.n.2016.86. (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 26842686 / ), and the literature cited here.

[0192] Information on telavancin can be found in the relevant Wikipedia entry (as of June 10, 2020), B. Das Ther Adv Infect Dis. 2017 Mar;4(2):49-73. doi: 10.1177 / 2049936117690501 (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 28634536 / ), and the literature cited here.

[0193] Information on teicoplanin can be found in the relevant Wikipedia entry (as of June 10, 2020), KW Shea Med Clin North Am. 1995 Jul;79(4):833-44. doi: 10.1016 / s0025-7125(16)30042-6 (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 7791426 / ), and in the literature cited here.

[0194] Information on dalbavancin can be found in the relevant Wikipedia entry (as of June 10, 2020), VR Anderson and GM Keating Drugs 2008;68(5):639-48; discussion 649-51. doi: 10.2165 / 00003495-200868050-00006. (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 18370443 / ), and in the literature cited here.

[0195] Information on ramoplanin can be found in the relevant Wikipedia entry (as of June 10, 2020), DK Farver et al. Ann Pharmacother. 2005 May;39(5):863-8. doi: 10.1345 / aph.1E397. Epub 2005 Mar 22 (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 15784805 / ), and the literature cited here.

[0196] Information on mannopeptimycin can be found in the Wikipedia article "Mannopeptimycin glycopeptide" (as of June 10, 2020), H. He Appl Microbiol Biotechnol. 2005 Jun;67(4):444-52. doi: 10.1007 / s00253-004-1884-z. Epub 2005 Feb 9 (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 15702316 / ), and in the literature cited here.

[0197] Information on lincomycin (and clindamycin) can be found in the relevant Wikipedia entry (as of June 10, 2020), J. Spνzek and T. Rezanka Appl Microbiol Biotechnol. 2004 May;64(4):455-64. doi: 10.1007 / s00253-003-1545-7. Epub 2004 Feb 5. (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 14762701 / ), and in the literature cited here.

[0198] Information on pyrlimycin can be found in the relevant Wikipedia entry (as of June 10, 2020), RD Birkenmeyer et al. J Med Chem. 1984 Feb;27(2):216-23. doi: 10.1021 / jm00368a020. (accessible via https: / / pubmed.ncbi.nlm.nih.gov / 6363698 / ), and in the literature cited here.

[0199] 5.8. Pharmaceutical composition

[0200] 5.8.1. Apabicin Composition

[0201] Apabicin may be administered orally, topically, transdermally, or parenterally, including particularly intravenously. Depending on the type of administration, the formulation will be adjusted in a suitable manner. Concurrently pending European patent application No. 19 157 255.1, filed February 14, 2019, and related international patent application PCT / EP2020 / 053882, filed February 14, 2020, describe suitable formulations designed for oral administration. The formulations described in these patent applications may also be used to practice the present invention. Accordingly, the disclosure of these applications is incorporated by reference in its entirety into this application.

[0202] In particular, it is preferable that the apabicin formulation for oral administration be a solid formulation selected from tablets and capsules. It is also preferable that such formulations contain a histidine compound. This may be histidine itself or a pharmaceutically acceptable salt of histidine. According to a particularly preferred embodiment, a tablet containing an inner phase (i.e., an inner granular phase) and an outer phase (i.e., an outer granular phase) is used, wherein apabicin is contained mainly or exclusively in the inner portion. The histidine compound is preferably present only in the inner phase.

[0203] The oral apabicin formulation preferably further contains one or more pharmaceutically acceptable excipients selected from binders, diluents, surfactants, disintegrants, etc.

[0204] For binder components, povidone (polyvinylpyrrolidone), copovidone (poly(1-vinylpyrrolidone-co-vinyl acetate)), hydroxypropyl cellulose, hydroxylpropyl methylcellulose, hydroxyethyl cellulose, methyl cellulose, microcrystalline cellulose, poloxamer (a block copolymer comprising a first poly(ethylene oxide) block, a second and central poly(propylene oxide) block, and a third poly(ethylene oxide) block), polyethylene glycol, magnesium aluminosilicate, gelatin, acacia, alginic acid, carbomer (e.g., Carbopol), carrageenan, dextrin, dextrate (a purified mixture of saccharides produced from the controlled enzymatic hydrolysis of starch), dextrose, polydextrose, guar gum, hydrogenated vegetable oil, liquid glucose, maltose, sucrose, lactose, wax, maltodextrin, starch (pregelatinized starch and It is preferable to select a binder from the group consisting of plain starch, hydroxypropyl starch, glyceryl behenate, glyceryl palmitostearate, polyethylene oxide, sodium alginate, ethylcellulose, cellulose acetate phthalate, polymethacrylate, sodium carboxymethyl cellulose, polycarbophil, chitosan, and mixtures thereof.

[0205] For diluent ingredients, mannitol, isomalt, lactose (including anhydrous or monohydrate forms), calcium phosphate (including dibasic and tribasic calcium phosphate), calcium carbonate, magnesium carbonate, magnesium oxide, calcium sulfate, sucrose, fructose, maltose, xylitol, sorbitol, maltitol, lactitol, trehalose, aluminum silicate, dextrose, cyclodextrin (natural or modified), starch (pregelatinized starch or plain starch), maltodextrin, cellulose (microcrystalline, silicified microcrystalline), glucose, dextrin, dextrate (purified saccharide mixtures produced through controlled enzymatic hydrolysis of starch), dextrose, polydextrose, ammonium alginate, glyceryl behenate, glyceryl palmitostearate, sodium alginate, ethylcellulose, cellulose It is preferable to select a diluent from the group consisting of acetate, cellulose acetate phthalate, polymethacrylate, chitosan, and mixtures thereof.

[0206] For surfactant components, it is preferable to select a surfactant from the group consisting of sodium lauryl sulfate, poloxamer, sodium docusate, sodium deoxycholate, sorbitan ester, polyethylene oxide, polysorbate 20, polysorbate 40, polysorbate 60, polysorbate 80 (ethoxysorbitan esterified with fatty acids (number refers to the number of repeating polyethylene glycol units)), sucrose esters of fatty acids, tiloxafol, lecithin, and mixtures thereof.

[0207] For the disintegrant component, it is preferable to select a disintegrant from the group consisting of crospovidone, sodium starch glycolate, sodium croscarmellose, magnesium aluminosilicate, colloidal silicon dioxide, sodium alginate, calcium alginate, gelatinized starch, microcrystalline cellulose, methylcellulose, hydroxypropyl cellulose, calcium carboxymethylcellulose, sodium carboxymethylcellulose, alginic acid, guar gum, homopolymers and copolymers of (meth)acrylic acid, salts thereof such as potassium polyacryline, and mixtures thereof.

[0208] In addition, cellulose-based excipients (i.e., those containing a cellulose-type backbone, wherein the hydroxyl groups of the cellulose backbone are C 1-6 Alkyl, Hydroxyl-C 1-6 Alkyl, Carboxy-C 1-6 Alkyl-(C=O)-C 1-6 It is preferable to rely on formulations that do not contain (which can be modified by various substituents such as alkyl). Additionally, it is preferable to avoid using starch materials as excipients similar to the description of the cellulose material above, and starch materials should be understood as materials having an amylose or amylopectin backbone structure in which the hydroxyl groups can be modified as described above.

[0209] When the apabicin formulation is administered orally, it is particularly preferable to administer a tablet having an inner and outer phase, and the individual phases have the following composition.

[0210] Internal phase:

[0211] 48 to 52 weight percent of apabicin olamin,

[0212] 17 to 21 weight percent of histidine

[0213] 4.75 to 6.75 weight% of binder,

[0214] 4.0 to 6.0 weight% of a surfactant, and

[0215] 1.6 to 3.6 weight% of disintegrant,

[0216] and external phase:

[0217] 10.5 to 14.5 weight% of a diluent (this content does not include the histidine compound described above)

[0218] 0.75 to 2.75 weight% of disintegrant,

[0219] 0.1 to 0.7 weight% of a lubricant, and

[0220] 2.0 to 4.0 weight% of lubricant.

[0221] As far as other forms of administration of apabicin are concerned, there are no specific restrictions. In particular, apabicin may be provided for topical, transdermal, or parenteral administration (intravenous, intramuscular, or subcutaneous), and each formulation is not specifically limited.

[0222] Topical apabicin formulations may be in the form of creams, lotions, gels, ointments, pastes, suspensions, drops, foams, and solutions.

[0223] Transdermal apabicin formulations can be wound dressings or transdermal patches.

[0224] Parenteral apabicin formulations may be solutions, suspensions, gels, solids (powders, lyophilized materials) that can be reconstituted before injection, antibiotic implants, e.g., apabicin, and optionally one or more additional agents selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, e.g., daptomycin and / or vancomycin and / or clindamycin, beads and / or spacers comprising these agents.

[0225] The cream may be a water-in-oil emulsion, an oil-in-water emulsion, or a multilayer emulsion. The cream may include micelles, liposomes, solvents, oils, surfactants, solubilizers, preservatives, and / or penetration enhancers.

[0226] The gel may include a gelling agent, a solubilizing agent, a solvent, a preservative, a penetration enhancer, and / or a surfactant.

[0227] Ointments and pastes may contain solvents, flow modifiers, surfactants, penetration enhancers, preservatives, oils and / or waxes.

[0228] Solutions, suspensions, foams, and drops may include solvents, solubilizers, viscosity modifiers, preservatives, penetration enhancers, and surfactants.

[0229] Formulations for parenteral administration, including intravenous, intramuscular, or subcutaneous administration, may be provided in solid form in vials so that they can be diluted in suitable solvents (e.g., water, aqueous NaCl solutions, e.g., 0.9 wt% NaCl solution, aqueous glucose solution, dextrose solution). In addition to the active ingredient, the solid component may contain buffers, solubilizers, stabilizers, volume extenders, osmotic agents, surfactants, and / or viscosity modifiers. Formulations for parenteral administration may also be provided in liquid form, e.g., infusion bags or pre-filled syringes. In this case, the liquid formulation may contain the same components listed above.

[0230] Additional parenteral administration types may also be considered, particularly comprising medical implants containing apabicin (and optionally one or more additional agents mentioned above and below, e.g., most preferably daptomycin and / or vancomycin and / or clindamycin) in the medical implant or in a coating on the medical implant.

[0231] In one embodiment, the parenteral administration type is an antibiotic implant provided to a patient solely for the purpose of releasing antibiotic(s). The antibiotic implant may comprise a bead of an inert material, such as poly(methyl methacrylate) (PMMA) or calcium sulfate, which carries apabicin (and optionally one or more additional agents mentioned above and below, e.g., daptomycin and / or vancomycin and / or clindamycin) within, for example, the pores and / or surface thereof. Alternatively, the antibiotic implant may comprise a mixture of a biodegradable matrix material, such as PLGA, and apabicin (and optionally one or more additional agents mentioned above and below, e.g., daptomycin and / or vancomycin and / or clindamycin). The mixed matrix releases the antibiotic over time, while the matrix material degrades within the patient's body. This embodiment may be useful for the therapeutic treatment of biofilm infections.

[0232] In another embodiment, the parenteral administration type is a medical implant implanted for (other) therapeutic reasons, such as an artificial joint. In this embodiment, it is optional to provide the surface of such medical implant with a coating comprising apabicin (and optionally one or more additional agents mentioned above and below, e.g., most preferably daptomycin and / or vancomycin and / or clindamycin). Such a coating may comprise a drug-containing layer and optionally additional layers, e.g., an adhesive layer below the drug-containing layer and / or an upper layer for release control. In addition to each drug, these layers may contain functional polymers such as polyvinylidene fluoride, polyethylene, polypropylene, polydimethylsiloxane, parylene, polyamide, polytetrafluoroethylene, poly(methyl methacrylate), polyimide and / or polyurethane. Alternatively, apabicin (and optionally one or more additional agents mentioned above and below, e.g., most preferably daptomycin and / or vancomycin and / or clindamycin) may be attached directly to the material of the medical implant or through a suitable spacer moiety. This embodiment may be useful for preventing biofilm infection.

[0233] A combination of apabicin and one or more additional agents mentioned above and below, e.g., daptomycin and / or vancomycin and / or clindamycin, may also be applied to medical devices, e.g., surgical instruments or sutures. This may prevent bacterial growth on said medical devices. That medical device, for example in the case of sutures, may deliver a combination of apabicin and one or more additional agents mentioned above and below to the surgical site or wound site.

[0234] As used herein, the term "medical instrument" refers to any tool used in a medical setting for the diagnosis or treatment of a patient, such as surgical tools like scalpels, forceps, scissors, and sutures.

[0235] The term "medical instrument" as used herein includes dental instruments.

[0236] 5.8.2. Composition of one or more additional formulations

[0237] There are no specific restrictions on the composition used to administer one or more additional agents. Generally, one or more additional antibiotics may be administered in any form that is commercially available and / or market-approved and / or generally recognized by the attending physician as safe and effective. It is convenient and therefore desirable to rely on the composition and dosage form of each approved and commercially available agent. For example, daptomycin and vancomycin are generally administered intravenously. Any formulation suitable for injection or infusion may be used.

[0238] These may contain the same components listed above in relation to apabicin. It is preferable to use commercially available Cubicin® and Vancocin® formulations, respectively.

[0239] Daptomycin and / or vancomycin may also be provided in formulations for topical administration. There are no specific limitations regarding the type of topical formulation. Again, the information provided above regarding topical apabicin formulations applies in a similar manner to topical daptomycin and / or vancomycin formulations. Furthermore, daptomycin and / or vancomycin may be provided as gels, for example, as described in WO 2015 / 118496, the entire disclosure of which is incorporated by reference.

[0240] Clindamycin is commercially available in various forms and dosage forms. All of these compositions may be used. While the use of commercially available compositions is preferred, the present invention is not limited to the use of such commercial compositions.

[0241] Similar considerations apply when using the other of the additional formulations described above and below. There are no restrictions regarding the form of administration, the type of composition, or excipients present in the composition.

[0242] 5.8.3. Combination Composition

[0243] If apabicin and one or more additional antibiotics are to be administered via the same route, the antibiotics may also be incorporated into the same pharmaceutical composition. For example, if apabicin is administered intravenously, it may also be provided in the form of a composition containing apabicin and one or more additional agents, such as, most preferably, daptomycin and / or vancomycin and / or clindamycin. This may be a composition similar, for example, to a commercial Cubicin® formulation. The commercial Cubicin® formulation contains daptomycin in powder form with sodium hydroxide as an excipient. This solid formulation is provided in the form of a vial for reconstitution with a 9 mg / ml (0.9%) sodium chloride solution. Thus, the combined formulation may consist of daptomycin, apabicin, sodium hydroxide, and an optional additional excipient (in solid form from reconstitution), or as a solution of these components in a 0.9% sodium chloride solution.

[0244] Similarly, an injectable combination formulation comprising apabicin and vancomycin or clindamycin, based on a commercial Vancocin® formulation or one of the commercially available clindamycin formulations, may be used.

[0245] In another embodiment, a composition comprising a combination of apabicin and one or more additional agents, such as daptomycin and / or vancomycin and / or clindamycin, is a composition for topical administration, and in particular, is a composition for topical administration of the same type as described above with respect to apabicin compositions and daptomycin compositions, such as gel compositions. According to one specific embodiment, such a topical composition may be a gel composition containing apabicin and one or more additional agents, most preferably daptomycin and / or vancomycin and / or clindamycin. Such a gel can advantageously be administered directly to an open window around an implant to ideally access the biofilm directly.

[0246] 5.9. Biofilm-related infections

[0247] 5.9.1. Types of Staphylococcus

[0248] The combination therapy of the present invention may be used to treat any biofilm infection, and preferably any biofilm infection containing or composed of any specific Staphylococcus species, including, for example, the following species:

[0249] - Staphylococcus species resistant to antibiotics commonly used to treat infections caused by Gram-positive bacteria, including but not limited to β-lactams such as penicillins (e.g., oxacillin, ampicillin) and cephalosporins (e.g., cefazolin, ceftaroline); fluoroquinolones such as vancomycin, linezolid, clindamycin, rifampicin, daptomycin, levofloxacin, and ciprofloxacin; tetracyclines such as trimethoprim / sulfamethoxazole, fosfomycin, fusidic acid, tigecycline, and doxycycline; and dalbavancin.

[0250] - Multidrug-resistant Staphylococcus strain

[0251] - Staphilococcus aureus

[0252] - Community-acquired Staphilococcus aureus

[0253] - Hospital-acquired Staphilococcus aureus

[0254] - Methicillin-susceptible Staphylococcus aureus (MSSA)

[0255] - Methicillin-resistant Staphylococcus aureus (MRSA)

[0256] - Staphylococcus aureus strains resistant to antibiotics commonly used to treat infections caused by Gram-positive bacteria, including but not limited to β-lactams such as penicillins (e.g., oxacillin, ampicillin) and cephalosporins (e.g., cefazolin, ceftaroline), fluoroquinolones such as vancomycin, linezolid, clindamycin, rifampicin, daptomycin, levofloxacin, and ciprofloxacin, tetracyclines such as trimethoprim / sulfamethoxazole, fosfomycin, fusidic acid, tigecycline, and doxycycline, and dalbavancin.

[0257] - Multidrug-resistant Staphylococcus aureus strain

[0258] - Coagulase-negative Staphylococci (CoNS)

[0259] - Coagulation enzyme-negative Staphylococcus strains resistant to antibiotics commonly used to treat infections caused by Gram-positive bacteria, including but not limited to β-lactams such as penicillins (e.g., oxacillin, ampicillin) and cephalosporins (e.g., cefazolin, ceftaroline), fluoroquinolones such as vancomycin, linezolid, clindamycin, rifampicin, daptomycin, levofloxacin, and ciprofloxacin, tetracyclines such as trimethoprim / sulfamethoxazole, fosfomycin, fusidic acid, tigecycline, and doxycycline, and dalbavancin.

[0260] - Multidrug-resistant CoNS strains

[0261] - Staphylococcus epidermidis

[0262] - Methicillin-resistant Staphylococcus epidermidis (MRSE)

[0263] - Methicillin-susceptible Staphylococcus epidermidis (MSSE)

[0264] - Staphylococcus epidermidis strains resistant to antibiotics commonly used to treat infections caused by Gram-positive bacteria, including but not limited to β-lactams such as penicillins (e.g., oxacillin, ampicillin) and cephalosporins (e.g., cefazolin, ceftaroline), fluoroquinolones such as vancomycin, linezolid, clindamycin, rifampicin, daptomycin, levofloxacin, and ciprofloxacin, tetracyclines such as trimethoprim / sulfamethoxazole, fosfomycin, fusidic acid, tigecycline, and doxycycline, and dalbavancin.

[0265] - Multidrug-resistant Staphylococcus epidermidis strain

[0266] - Staphylococcus haemolyticus

[0267] - Staphylococcus lugdunensis

[0268] - Staphylococcus simulans

[0269] - Staphylococcus hominis

[0270] - Staphylococcus arlettae

[0271] - Staphylococcus auricularis

[0272] - Staphylococcus capitis

[0273] - Staphylococcus caprae

[0274] - Staphylococcus cohnii

[0275] - Staphylococcus equorum

[0276] - Staphylococcus gallinarum

[0277] - Staphylococcus jettensis

[0278] - Staphylococcus kloosii

[0279] - Staphylococcus lentus

[0280] - Staphylococcus massiliensis

[0281] - Staphylococcus pasteuri

[0282] - Staphylococcus pattenkoferi

[0283] - Staphylococcus petrasii

[0284] - Staphylococcus saccharolyticus

[0285] - Staphylococcus saprophyticus

[0286] - Staphylococcus schleiferi

[0287] - Staphylococcus sciuri

[0288] - Staphylococcus succinus

[0289] - Staphylococcus vitulinus

[0290] - Staphylococcus warneri

[0291] - Staphylococcus xylosus

[0292] In certain embodiments, Staphylococcus bacteria are selected from CoNS such as Staphylococcus aureus and S. epidermidis. This includes all antibiotic-resistant strains, including but not limited to MRSA, MRSE, and rifampicin-resistant strains.

[0293] Of course, the combination therapy of the present invention may also be used to treat biofilm-mediated bacterial infections containing two or more Staphylococcus species. Similarly, the biofilm-mediated infection to be treated may include Staphylococcus species along with other microorganisms (e.g., bacteria, fungi). In such cases, it may be advantageous to use one or more additional antibiotics suitable for treating the additionally present microorganisms. This is particularly important if the additionally present microorganisms are not susceptible to apabicin treatment or are not susceptible to daptomycin and / or vancomycin.

[0294] 5.9.2. Sites and Types of Biofilm Infection

[0295] Biofilms can form on various parts of the human body, including, for example, the intrinsic surfaces of body parts (dental materials, bones, etc.) or external surfaces (e.g., contact lenses, artificial joints, etc.). Consequently, various infections that may be associated with biofilms, particularly those containing Staphylococcus bacteria, are known. These include the following:

[0296] o Medical implant-related infections

[0297] o Osteomyelitis;

[0298] o Infection in patients with cystic fibrosis;

[0299] o Pleuropulmonary infection, e.g., pneumonia, preferably the pleuropulmonary infection is chronic, and more preferably the pleuropulmonary infection is an obstructive lung disease;

[0300] o Endocarditis, preferably native valve endocarditis;

[0301] o Wound infection, preferably chronic wound infection;

[0302] o Mastitis;

[0303] o Sinusitis, preferably chronic sinusitis;

[0304] o Otitis media, preferably chronic otitis media;

[0305] o Urinary tract infection;

[0306] o Tonsillitis, preferably the tonsillitis is chronic;

[0307] o Laryngitis, preferably chronic laryngitis;

[0308] o Infection associated with kidney stones;

[0309] o Biliary tract infection;

[0310] o Aerobic vaginitis;

[0311] o Septic thrombophlebitis;

[0312] o Infections associated with intracellular biofilms, e.g., infections associated with intracellular biofilms in Kupffer cells or tonsil cells; and

[0313] o Colonization by Staphylococcus aureus, which carriers are susceptible to infection.

[0314] Medical implant-associated infections may be infections associated with any medical implant. For example, joint prostheses, orthopedic implants, heart valves, breast implants, ventricular shunts, pacemakers, defibrillators, ventricular assist devices, vascular grafts, endotracheal tubes, artificial larynges, soft tissue fillers (including permanent or semi-permanent tissue fillers), catheter-associated infections, e.g., infections of central venous catheters, peripheral vascular catheters, peritoneal dialysis catheters, urinary catheters, and keratitis caused by biofilms from contact lenses. In particular, medical implant-associated infections are infections associated with medical implants that are permanent retained devices, e.g., joint prostheses, orthopedic implants, heart valves, breast implants, ventricular shunts, pacemakers, defibrillators, ventricular assist devices, and vascular grafts. Infections associated with medical implants include the infections listed above, for example, osteomyelitis that may occur either naturally or in association with the medical implant.

[0315] There are no particular limitations regarding the sites and types of biofilm infections that can be treated by the means and methods of the present invention. According to a preferred embodiment, the combination therapy of the present invention is used to treat biofilm-associated prosthetic joint infections (PJI).

[0316] As mentioned above, all references to medical indications that may or may not be related to biofilm formation are intended to specifically refer to the form of each medical indication, where the biofilm is actually formed or presumed to be formed. For example, artificial joint infection is intended to refer to an artificial joint infection where a biofilm is actually formed or presumed to be formed.

[0317] 5.10. Treatment Methods

[0318] 5.10.1. Dosage

[0319] As mentioned above, apabicin can be used in the form of a free acid, an olamin salt (or any other suitable salt form), or a combination of these different forms. The dosage indications provided for apabicin refer to the amount in the free acid form. When using apabicin salts, the dosage must be adjusted accordingly, taking into account the high molecular weight of the apabicin salt. This is most easily done with absolute dosage indications in mg units. The adjusted value can be converted to a relative amount if necessary.

[0320] Typically, a single unit dose of the apabicin formulation is administered at least once a day, and twice a day is preferred. The daily dose is determined by the attending physician in consideration of the severity of the infection, sex, body weight, age, and the patient's general condition. The typical daily dose range for humans is 120 to 480 mg. The typical daily dose is 120 or 240 mg twice a day, with a total of 240 to 480 mg per day. Accordingly, the present invention relies on a unit dose strength of preferably 120 mg or 240 mg of the active pharmaceutical ingredient (calculated as apabicin; for example, if apabicin olamin is used, the preferred unit dose strength in terms of the total weight of apabicin olamin is 150 mg or 300 mg).

[0321] Daptomycin may be administered at a total daily dose of 0.1 to 10 mg / kg. More preferably, daptomycin is administered in accordance with the instructions provided in Section 4.2 of the Summary of Product Characteristics for Cubicin®, particularly including the following administration details:

[0322] - Complicated skin and soft-tissue infections (cSSTI) not accompanied by concomitant Staphylococcus aureus bacteraemia (SAB): Administer Cubicin 4 mg / kg once every 24 hours for 7-14 days or until the infection is resolved (see Section 5.1).

[0323] - cSSTI with concomitant Staphylococcus aureus bacteremia (SAB): Administer Cubicin 6 mg / kg once every 24 hours. The duration of treatment may require more than 14 days depending on the perceived risk of complications in the individual patient.

[0324] - In cases where right-sided infective endocarditis (RIE) caused by Staphylococcus aureus is known or suspected: Administer Cubicin 6 mg / kg once every 24 hours.

[0325] Vancomycin may be administered intravenously according to the following administration details:

[0326] - Patients 12 years of age or older: The recommended dose is 15 to 20 mg per kg of body weight administered every 8 to 12 hours (not exceeding 2 g per dose). For severe patients, a loading dose of 25 to 30 mg per kg of body weight may be used to rapidly reach the target trough serum vancomycin concentration.

[0327] - Infants and toddlers aged 1 month to under 12 years: The recommended dose is 10 to 15 mg per kg of body weight administered every 6 hours.

[0328] Clindamycin may be administered to adults by intravenous or intramuscular injection in 2, 3, or 4 doses at a daily dose of 600 mg to 1.2 g for serious infections and 1.2 to 2.7 g for more severe infections. For children, the dosage may be 15-25 mg / kg / day for serious infections and 25-40 mg / kg / day for more severe infections, in 3 or 4 doses.

[0329] When another agent selected from other antibiotics, namely lipopeptides, glycopeptides, and lincosamides, is used as one or more additional agents, it is recommended to select the dosage, type of administration, frequency of administration, and any other relevant details based on the established and / or approved treatment of said agent.

[0330] The dosage, frequency of administration, and / or duration of administration may be adjusted according to the patient's condition. For example, if the patient's condition is severe or only a slow response to treatment is observed, daptomycin may be administered at a dose of 4 mg / kg or 6 mg / kg at a frequency shorter than 24 hours and / or for a period longer than 7 to 14 hours. The dosage and frequency of administration of vancomycin, or other agents belonging to the lipopeptide, glycopeptide, and lincosamide groups, e.g., daptomycin or clindamycin, may also be adjusted as needed depending on the individual patient's condition.

[0331] 5.10.2. Type of Administration

[0332] Apabicin can be administered orally, topically, transdermally, or parenterally, including particularly intravenously. When the active metabolite Debio 1452 is used as the apabicin compound, this drug can be administered orally or topically.

[0333] There are no specific restrictions on one or more other formulations selected from lipopeptides, glycopeptides, and lincosamides. Any administration suitable for the formulation of interest may be used. Approved formulations of administration are preferred, particularly where the corresponding pharmaceutical composition is commercially available. For example, daptomycin and vancomycin are generally administered intravenously. However, topical formulations such as gels are known. According to the present invention, it is possible to administer daptomycin and / or vancomycin intravenously, topically, or in combination of both. If additional formulations of daptomycin and / or vancomycin are developed in the future, it may also be possible to rely on these additional formulations to practice the present invention. For example, one can conceive of administering apabicin and / or daptomycin and / or vancomycin as a coating on the surface of a medical implant or inside or on top of an antibiotic implant. Similar considerations apply to other formulations belonging to the group of lipopeptides, glycopeptides, and lincosamides.

[0334] When a patient is treated using an algorithm involving different steps, apabicin may be administered intravenously in the first step and orally in the second step (or vice versa). The steps may be repeated in the same or different order. In this multi-step treatment, the administration of one or more other agents is not particularly restricted, except that it is limited to the dosage forms available or at least suitable for this drug.

[0335] In this multi-step treatment, intravenous or oral administration may be replaced or supplemented by other routes of administration or combinations thereof (e.g., topical administration of apabicin and / or topical administration of daptomycin and / or topical administration of vancomycin and / or topical administration of clindamycin).

[0336] 5.10.3. Use of additional drugs

[0337] As specified in the appended claims, additional drugs may be used in addition to the drug combination of the present invention. In principle, there are no particular limitations on the additional drugs that may be used. According to a preferred embodiment, the additional drug (or co-drug) is selected from antibiotic compounds. Suitable co-drugs are listed, for example, in paragraphs

[0131] –

[0140] and claims 32–34 of WO 2013 / 190384 A. Specific co-drugs including those mentioned in WO 2013 / 190384 A are listed below.

[0338] Possible co-drugs include other Fabl inhibitors, other antibiotics, or antimicrobial agents as described below.

[0339] Non-limiting examples of antibiotics that can be used as co-drugs include cephalosporins, quinolones and fluoroquinolones, penicillins, penicillins and beta-lactamase inhibitors, carbepenems, monobactams, macrolides and lipoglycopeptides, rifamycin, oxazolidonones, tetracyclines, aminoglycosides, streptogramins, sulfonamides, etc. Each family consists of many members.

[0340] Cephalosporins can be further classified by generation. Suitable non-limiting examples of cephalosporins by generation include the following. Examples of cephalosporins - First-generation compounds include cephadroxyl, cefazolin, cephalexin, cephalotin, cepapyrin, and cefradine. Second-generation compounds include cephaclo, cefamandol, cefofenid, cefotetan, cefoxitin, cefprozil, cefmethazole, cefuroxim, cefuroxim axetyl, and loracarbep. - The third generation includes cefdinir, ceftibutene, cefditoren, cepetamet, cefbodoxime, cefprozil, cefuroxime (axetyl), cefuroxime (sodium), cefoperazone, cefixim, cefotaxim, cefodoxime proxetyl, ceftazidime, ceftizoxime, cefcapene, cefdaloxime, cefmenoxime, cepyramid, and ceftriaxone. The fourth generation compounds include cefepim. The fifth generation compounds include ceftaroline fosamil, ceftolozane, and ceftobiprol.

[0341] Non-limiting examples of suitable quinolones and fluoroquinolones include cinoxacin, ciprofloxacin, enoxacin, gatifloxacin, grepafloxacin, levofloxacin, romefloxacin, besifloxacin, finafloxacin, moxifloxacin, nalidixin, norfloxacin, ofloxacin, sparfloxacin, trovafloxacin, oxolinic acid, gemifloxacin, perfloxacin, nemonoxacin, and novobiocin.

[0342] Non-limiting examples of suitable penicillins include amoxicillin, ampicillin, bacampicillin, carbenicillin indanil, mezlosillin, piperacillin, and ticarcillin.

[0343] Non-limiting examples of suitable penicillins and beta-lactamase inhibitors include amoxicillin-clavulanic acid, ampicillin-sulbactam, benzylpenicillin, cloxacillin dicloxacillin, methicillin, oxacillin, penicillin G (benzathine, potassium, procaine), penicillin V, piperacillin+tazobactam, ticarcillin+clavulanic acid, and naphsylline.

[0344] Non-limiting examples of suitable carbepenems include doripenem, ertapenem, imipenem-cilastatin, and meropenem. Non-limiting examples of suitable monobactams include aztreonam. Non-limiting examples of suitable macrolides and lincosamines include azithromycin, clarithromycin, dirithromycin, erythromycin, flurithromycin, josamycin, midecamycin, myocamycin, oleandomycin, rokitamicin, roxithromycin, spiramycin, tylosin, ketolides, and trolandomycin. Non-limiting examples of suitable rifampin include rifabutin, rifampin, and rifapentine. Non-limiting examples of suitable oxazolidonones include linezolid, eperezolid, pozizolid, radelozide, lanbezolid, sutesolid, and tedizolid. Non-limiting examples of suitable tetracyclines include demeclocycline, doxycycline, metacycline, minocycline, oxytetracycline, tetracycline, clomocycline, limecycline, meclocycline, phenimepicycline, roliteteracryline, tigecycline, and chlortetracycline.

[0345] Non-limiting examples of suitable aminoglycosides include amikacin, arbacasin, gentamicin, kanamycin, sisomycin, arbecasin, neomycin, netilmycin, streptomycin, tobramycin, bekanamycin, ribostamycin, spectinomycin, hygromycin B, dihydrostreptomycin, verdamycin, astromycin, and paromomycin. Non-limiting examples of suitable streptogramins include quinopristine + dalfopristin, pristinamycin, and virginiamycin.

[0346] Suitable non-limiting examples of sulfonamides include mafenide, sulfadiazine, sulfacetamide, sulfadiazine, sulfamethoxazole, sulfasalazine, sulfisoxazole, trimethoprim-sulfamethoxazole, sulfamethizol, sulfamethizol, sulfadimidine, sulfapyridine, sulfafurazole, sulfanilamide, sulfatiazole, sulfatiourea, sulfamoxol, sulfadimethoxine, sulfadoxine, sulfalene, sulfamethomidine, sulfamethoxydiazine, sulfamethoxypyradazine, sulfaferine, sulfamerazine, sulfafenazole, and sulfamazone.

[0347] Non-limiting examples of other suitable antibiotics include bacitracin, chloramphenicol, azidamfenicol, thiamphenicol, florfenicol, retapamulin, tiamulin, balnemulin, fusidic acid, colistimetate, fosfomycin, isoniazid, methenamine, metronidazole, tinidazole, omidazole, mupirocin, nitrofurantoin, nitrofurazone, nifurtoinol, novobiocin, polymyxin B, spectinomycin, tobramycin, tigecycline, trimethoprim, brodimorphim, tetroxoprim, colistin, polymyxin B, gramicidin, isoniazid, teixobactin, cycloserine, capreomycin, pyrazinamide, para-aminosalicylic acid, and erythromycin ethylsuccinate + sulfisoxazole.

[0348] If it is decided to use a combination with one or more of these additional drugs, the indications of the present invention regarding the form of administration, dosage, etc., may need to be appropriately adjusted in consideration of the characteristics of the additional co-drugs. The one or more of the aforementioned additional co-drugs may be administered before, simultaneously with, and / or after the administration of the apabicin-containing drug combination of the present invention.

[0349] According to another preferred embodiment of the present invention, no additional antibiotics are used, that is, treatment comprises the administration of a drug combination consisting of apabicin and one or more additional antibiotics selected from lipopeptides, glycopeptides, and lincosamides. According to another preferred embodiment of the present invention, treatment comprises the administration of a drug combination consisting of apabicin and one or more additional antibiotics selected from lipopeptides, glycopeptides, and lincosamides, and optionally, one or more additional antibiotics as specified in this section, but rifampicin is excluded as an additional antibiotic.

[0350] 5.10.4. Timing of Administration

[0351] In most embodiments, administration of the apabicin-containing drug combination of the present invention should be started as soon as possible and continued for a sufficiently long period to ensure therapeutic success. The required duration of treatment depends on the specific type of infection, the patient's overall condition, age, comorbidities, etc., and can be determined by the attending physician.

[0352] Some embodiments of the present invention relate to the treatment of biofilm-mediated bacterial infections, and preferably biofilm-mediated Staphylococcus bacterial infections associated with, for example, medical implants (temporary or permanent retained medical devices), such as catheter-associated infections, artificial joint infections, or infections associated with soft tissue fillers. A preferred embodiment relates to the treatment of PJI. For such embodiments, the following scenarios and associated treatments may be considered to implement the present invention:

[0353] (i) If the patient exhibits a symptom duration of 3 weeks or less, or if an infection occurs within 4 weeks after implantation, if the medical implant is stable, and if there is no sinus tract, the treatment method may include the maintenance of the medical implant (artificial joint). In this case, it is desirable to remove necrotic tissue through debridement. This procedure is preferably followed by a primary treatment phase in which the drug combination of the present invention is administered intravenously. This primary treatment phase may generally last for 2 to 6 weeks. Subsequently, depending on the patient's condition, a secondary treatment phase may follow, which is advantageously administered after the primary treatment phase, in which the drug combination of the present invention is administered orally, while one or more additional agents such as daptomycin and / or vancomycin and / or clindamycin are administered intravenously. The duration of the secondary treatment phase varies depending on the patient's condition and may generally last from 6 to 10 weeks. Shorter or longer treatment times may also be considered. If the patient's condition is poor, extending the first treatment phase to, for example, 10 or 12 weeks may be considered. Typically, the second treatment phase is the same as or longer than the first treatment phase.

[0354] (ii) If all of the above conditions summarized in item (i) are not simultaneously satisfied, i.e., if the medical implant (artificial joint) is unstable and / or the presence of a sinus tract is observed, the medical implant (artificial joint) is preferably replaced.

[0355] (ii-1) If the tissue surrounding the medical implant (artificial joint) is intact or only slightly damaged, the replacement of the medical implant (artificial joint) can be performed as a one-stage procedure. After that, the two treatment stages summarized in item (i) above follow.

[0356] (ii-2) In the presence of soft tissue damage, abscess, or sinus tract, it is desirable to perform a two-stage exchange with a short interval between removal and implantation. The short interval may typically range from 2 to 4 weeks. The aforementioned first treatment stage using the drug combination of the present invention occurs at least during this short interval. The implantation of a new medical implant (artificial joint) may be followed by another period of the first treatment stage followed by a second treatment stage, or the second treatment stage may follow alone.

[0357] In cases where biofilms are difficult to treat, the period between removal and transplantation may be extended. For example, after removing a medical implant (artificial joint), there is a 6-week period of the primary treatment phase, followed by no administration of antibiotics for 2 weeks, after which the transplantation of a new medical implant follows, and then additional intravenous administration is performed according to the primary treatment phase until the culture results are determined.

[0358] (iii) When the patient is inoperable, debilitated, or bedridden, it is appropriate to perform long-term inhibitory antimicrobial treatment using the drug combination of the present invention. In this case, treatment / administration of both the first and second treatment stages described above is possible, and the medical professional may select the appropriate method depending on the specific circumstances of the case.

[0359] (iv) If functional improvement is not expected even after replacing the medical implant (artificial joint), it may be most appropriate to remove the medical implant (artificial joint) without replacement. This procedure may also preferably be followed by treatment using the drug combination of the present invention, which includes a two-step treatment as summarized in item (i) above.

[0360] The treatment scenario described in detail above is schematically shown in Figures 1 and 2.

[0361] The above general rules can be applied in a similar manner to cases of biofilm-mediated infections associated with medical implants other than artificial joints. However, it may be advantageous to adjust the sequence of the periods and steps mentioned above depending on the patient's condition and the type and size of the medical implant. Alternative treatment strategies may be performed or guided by the recommendations included in Bennett J et al. eds. in Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, Vol 1. 8th ed. Philadelphia, PA; Elsevier 2015:1328-35.

[0362] 5.11. Abbreviations

[0363] ACN: Acetonitrile

[0364] AM: Analytical method

[0365] BES: bis-ethanolamine salt

[0366] bid: twice daily (bis in die)

[0367] BLOQ: Below the lower limit of quantification

[0368] C: Calibration Standards

[0369] CFU: Colony-forming units

[0370] cSSTI: Complicated skin and soft-tissue infections

[0371] CV(%): Precision: Coefficient of Variation = 100 × SD / Average

[0372] D or d: day

[0373] DAP: Daptomycin

[0374] DMSO: Dimethyl sulfoxide

[0375] ESI: Electrospray Ionization

[0376] FA: Formic Acid

[0377] GLP: Good Laboratory Practice

[0378] HED: Human Equivalent Dose

[0379] IS: Internal Standard

[0380] ip or IP: Intraperitoneal

[0381] ISR: Incurred Sample Reproducibility

[0382] LC: Liquid Chromatography

[0383] LC-MS / MS: Liquid Chromatography - Tandem Mass Spectrometry

[0384] LLOQ: Lower Limit of Quantification

[0385] LOD: Limit of Detection

[0386] MeOH: methanol

[0387] MIC: Minimal inhibitory concentration

[0388] MHA: Mueller-Hinton agar

[0389] MRM: Multiple Reaction Monitoring

[0390] MRSA: Methicillin-resistant Staphylococcus (S.) aureus

[0391] MS / MS: Tandem Mass Spectrometry

[0392] NH3: Ammonium Hydroxyde

[0393] Nt: not tested

[0394] OI: Operational Instruction

[0395] o / n: overnight

[0396] PBS: Phosphate buffered saline

[0397] PJI: Prosthetic joint infection

[0398] PK: Pharmacokinetics

[0399] PO: Orally (orally (per os))

[0400] QC: Quality Control

[0401] QD or qd: once daily (once daily (quaqua die))

[0402] qdam: once a day in the morning (quaque die ante meridiem)

[0403] RIE: right-sided infective endocarditis

[0404] RIF: Rifampicin

[0405] RT: Room Temperature

[0406] S: Staphylococcus

[0407] SA: Staphylococcus aureus

[0408] SAB: Staphylococcus aureus bacteraemia

[0409] SC: Subcutaneous

[0410] SD: Standard Deviation

[0411] SOC: Standard of Care

[0412] SOP: Standard Operating Procedure

[0413] TCF: Tissue cage fluid

[0414] ULOQ: Upper Limit of Quantification

[0415] UPLC: Ultra-Performance Liquid Chromatography

[0416] 6. Example

[0417] 6.1. Example 1: Evaluation of the activity of Debio 1450 BES as a single agent or in combination with an anti-staphylococcal compound against 24-hour and 72-hour MRSA biofilms in an in vivo murine model of catheter-associated infection

[0418] In this study, two experimental environments were used to evaluate the therapeutic efficacy against early (24-hour) and / or mature (72-hour) MRSA catheter-forming biofilms. Briefly, mice were anesthetized with an IP injection of approximately 120 μl of a mixture of ketamine (50 mg / kg) and xylazine (10 mg / kg) (4 mL ketamine + 2 mL xylazine + 10 mL saline). The right flank was shaved and disinfected by applying Betadine three consecutive times. Under sterile conditions, a 0.2 cm skin incision was made followed by a subcutaneous (SC) incision, and a 1 cm long polyurethane catheter (Ref. No. ES-04730 Arrow international), cut into two longitudinal segments, was inserted into the SC (inserted through the incision and then pushed further under the skin approximately 2 cm away from the incision). Inoculation was performed simultaneously by placing 50 μl of bacterial culture solution into the catheter. The incision was sutured and disinfected. The day of infection was designated as Day 0 (D0). To ensure that the study was conducted under sterile conditions from the start to the end of the experiment, uninfected mice (Sentinel group) were included. Treatment was initiated at D1 or D3 post-infection, corresponding to early (24 hours) or more mature (72 hours) catheter-forming biofilms, respectively, and continued for 5.5 days (D1-D6) or (D3-D8). Bacterial counts were evaluated in the two groups of infected untreated animals (vehicle control) in 24-hour and 72-hour biofilm environments: at baseline (24 hours post-infection or D1 [for 24-hour biofilms] and 72 hours post-infection or D3 [for 72-hour biofilms]), i.e., the time corresponding to the start of treatment), and at the end of the treatment period (D6 [for 24-hour biofilms] and D8 [for 72-hour biofilms]). CFU after treatment was calculated on D6 or D8, and the results were Log 10 Expressed as CFU / catheterg (mean ± SEM). The detection limit is 1 Log 10It was determined as CFU / catheterg (ΔLog) from baseline (D1 or D3 for 24-hour and 72-hour biofilms, respectively) and cure rate (corresponding to the percentage of mice free of catheter-associated bacteria within a given treatment group). 10 Changes in ) were also calculated. In vivo induction of antibiotic-resistant bacteria was analyzed for all tested antibiotics.

[0419] The antibiotic dosage was selected based on the effective dose in animals that is close to the therapeutic human equivalent dose (HED) (Table 1).

[0420] Dose level (mg / kg) Administration route Frequency Therapeutic Human Equivalent Dose (HED) note Debio 1450 BES 50 PO BID 240 mg BID PO or 480 mg / day daily dose Slightly higher than HED and used in monotherapy and combination therapy (for 24-hour and 72-hour biofilms) Daptomycin 120 IP QD >6 mg / kg QD IP Tested in monotherapy and combination therapy settings (for 24-hour and 72-hour biofilms) Rifampicin 30 IP BID 10-15 mg / kg BID IP Tested in monotherapy and combination therapy settings (for 24-hour and 72-hour biofilms) vancomycin 110 SC BID 1g IV every 12 hours, 2 to 3g / day Tested in monotherapy and combination therapy settings (for 24-hour and 72-hour biofilms)

[0421] Mice were administered antibiotics at D1, D2, D3, D4, D5, and D6 (a single dose at D6) or D3, D4, D5, D6, D7, and D8 (a single dose at D8). With the exception of Debio 1450 BES and vancomycin, which were administered PO and SC respectively, all antibiotics were administered via BID IP. Daptomycin was tested as a once-daily regimen to avoid tolerability issues. Daily antibiotic administration was performed at intervals of 10–12 hours between doses. For combination therapy, antibiotics were administered concurrently at intervals of 10–12 hours (the time between the first and second antibiotic infusions was less than 30 seconds per mouse).

[0422] In each sub-study, animals were randomly assigned to either antibiotic therapy or vehicle control.

[0423] The volume was calculated based on the individual body weight of each animal.

[0424] After blood collection, animals were sacrificed by cervical dislocation following anesthesia. Two catheter fragments were collected per mouse and used for bacterial counting after sonication. Each catheter fragment was washed individually in an Eppendorf tube under sterile conditions (three consecutive washes with 300 μl sterile saline). After the final wash, the catheter was suspended in 1 mL sterile saline, placed in an ultrasound bath (Advantage Lab) at room temperature for 3 minutes, and then vigorously vortexed to detach any bacteria attached to the catheter. Several serial dilutions of this suspension (undiluted, 10 -2 , 10 -4 ) was cultured on Chapman agar plates at 37°C for 48 hours. If necessary, dilution was repeated in cases where there was no certainty that the stability of the bacterial suspension at 4°C had been verified beforehand or in cases where the results were insufficient. Bacterial colony counting was performed manually, and the number of CFU / mL was determined and adjusted for g of the catheter.

[0425] Since no bacterial growth was observed on the implanted catheters in Sentinel mice, the study was conducted under sterile conditions overall. Bacterial load remained stable for 5.5 days in the vehicle control group (24h and 72h biofilms). The results of the 5.5-day monotherapy and combination therapy on 24-hour and 72-hour MRSA biofilms are summarized in Table 2. Daptomycin / rifampicin was used as the standard of care (SOC) combination and served as the control drug throughout the entire study.

[0426] In a monotherapy setting, rifampicin (30 mg / kg BID IP) demonstrated the highest activity among all antibiotics tested against both 24-hour and 72-hour MRSA biofilms, reducing the initial MRSA load of the catheter by 4.17±0.072 Log 10 CFU / catheterg and 2.98±0.113 Log 10The mean reduction in CFU / g catheter was 39% and 8%, respectively. The SOC combination of daptomycin (120 mg / kg QD IP) + rifampicin (30 mg / kg BID IP) demonstrated the most pronounced efficacy against 24- and 72-hour biofilms, showing cure rates of 58% and 25%, and reducing the initial MRSA load by 5.00±0.069 Log of the catheter. 10 CFU / catheterg and 3.52±0.135 Log 10 Each CFU / catheter was reduced on average.

[0427] While the monotherapy of Debio 1450 BES at 50 mg / kg BID PO exhibited a relatively weak anti-biofilm effect, the combination of Debio 1450 BES (50 mg / kg BID PO) + daptomycin (120 mg / kg QD IP) demonstrated activity similar to the SOC of rifampicin / daptomycin. Debio 1450 BES / daptomycin showed cure rates of 42% and 17% in the 24-hour and 72-hour biofilm environments, respectively, and the initial catheter MRSA load was 4.38 ± 0.105 Log, respectively. 10 CFU / catheterg and 3.36±0.121 Log 10 Reduced to CFU / catheter g.

[0428] A second promising combination therapy for 24-hour and 72-hour biofilms consisted of Debio 1450 / vancomycin (mean Log 3.69±0.118 and 2.99±0.162 in 24-hour and 72-hour biofilm environments). 10 Reduction in CFU / catheter g, 25% and 17% cure rates, respectively). However, neither Debio 1450 nor vancomycin showed excellent anti-biofilm activity when used as monotherapy.

[0429] Induction of resistance studies in single and combination therapies (determined after in vitro bacterial exposure to 4XMICs of Debio 1452, daptomycin, rifampicin, or vancomycin) did not show the emergence of resistance mutations regardless of the antibiotic tested or the biofilm setting model (24-hour or 72-hour biofilm).

[0430] [Table 2]

[0431] Summary of bacterial load on catheters after 5.5 days of treatment of BALB / c mice with single or combination antibiotics in a 24- or 72-hour biofilm environment. Results are Log at the end of treatment (D6 and D8) for 24-hour and 72-hour biofilms, respectively. 10 CFU / catheter g and Log from pre-treatment baseline (D1 or D3 for 24-hour and 72-hour biofilms, respectively) 10 Change in CFU / catheterg (ΔLog 10 It is displayed as ). The mean ± standard error of the mean (SEM) is displayed. The cure rate (CR, %) is presented. Log 10 The statistical significance (p) of CFU / catheterg was determined using ANOVA (completed by Bonferroni post-hoc test). *: p<0.05; **: p<0.005; ***: p<0.001. NS = not significant, NT = not tested.

[0432]

[0433] In conclusion, the Debio 1450 BES / daptomycin and Debio 1450 BES / vancomycin combinations showed significant anti-biofilm activity similar to that of SOC rifampicin / daptomycin. Therefore, the Debio 1450 / daptomycin and Debio 1450 / vancomycin combinations could be strong candidates for the limited treatment options for biofilm-mediated MRSA infections.

[0434] 6.2. Example 2: Efficacy of Debio 1450 BES in a Mouse Tissue Cage Model of MRSA Infection

[0435] The purpose of this study was to evaluate the efficacy of Debio 1450 BES alone and in combination with daptomycin (DAP) in a mouse tissue cage model of implant-associated infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The efficacy against 24-hour biofilms of S. aureus ATCC 43300 (MRSA) was investigated and compared to the standard treatment combination of rifampicin (RIF) and DAP at human equivalent doses. Using a small initial inoculum (ca. 300 CFU / cage) with 24-hour biofilms can simulate the clinical setting of acute implant infection and / or surgical necrotic tissue removal.

[0436] The tissue cage model for artificial joint infection is very well established and closely mimics human artificial joint infection. This model is based on the subcutaneous insertion of a tissue cage after experimentally infecting the foreign body by injecting a bacterial inoculum into the cage.

[0437] Briefly, sterile polytetrafluoroethylene (Teflon) cylinders (32 x 10 mm) (tissue cages, Angst-Pfister AG, Zürrich), perforated at regular intervals with a diameter of 1 mm, were aseptically subcutaneously implanted on the backs of C57BL / 6 mice (minimum weight 20 g). The experiment was initiated after complete wound healing (at least 2 weeks post-surgery). For the efficacy study presented herein, the cages of all animals were infected with approximately 300 colony-forming units (CFU) per cage, and a biofilm was developed for 24 hours prior to the start of treatment.

[0438] Animals received antibiotic treatment via ip (Debio 1450 BES and DAP) or sc (RIF) on days 1, 2, 3, 4, 5, and 6 (administered only in the morning on day 6). One group received only 5% glucose and served as an infected untreated control (vehicle). The treatment duration and antibiotic dosage were selected to better compare the results of this study with those of Example 1, where the Debio 1450 BES (50 mg / kg) / DAP (120 mg / kg) combination demonstrated a 42% cure rate for 24-hour MRSA biofilms. Debio 1450 and the vehicle were administered via bid and qdam on day 6. DAP and RIF were administered via qdam. Debio 1450 BES at a dose of 50 mg / kg was selected as the HED. A DAP dose of 100 mg / mL was selected because it is closely correlated with a human clinical dose of 10 mg / kg once daily. A RIF dose of 25 mg / kg is the most commonly used for the treatment of experimental biofilm infections.

[0439] The sterility of the transplanted cages was confirmed by aspirating TCF and plating it on blood agar plates 5 to 6 days prior to infection. To confirm the establishment of infection, TCF was aspirated and plated on day 1 (before treatment). Additionally, bacterial counts within the TCF were measured on days 3 (the day before the first injection), 6 (before final treatment), and 9 (before cage transplantation) to evaluate therapeutic efficacy against planktonic bacteria. The number of mice and bacteria in a given cage were reported to analyze the time course of the antimicrobial activity of the test drug. Efficacy against biofilm-gut bacteria was evaluated qualitatively and quantitatively after sterile transplantation of the tissue cages 3 days after the completion of treatment. A 3-day rest period helps avoid antibiotic carryover effects. For explantation, the cages were washed twice with phosphate-buffered saline (PBS) (Lot 5060914) and immediately transferred to 5 mL of 0.9% NaCl (Lot L161619 or L162658). The number of bacteria dispersed in the biofilm was determined by plating after 30 seconds of vortexing, sonication (3 minutes at 130 W), and an additional 30 seconds of vortexing. The sonicated cages were washed once with PBS, transferred to 5 mL of TSB (Lot 0286463), and incubated at 37°C for 48 hours, followed by an additional vortexing step after 24 hours of incubation. After incubation, the tubes were vortexed again, and bacterial regrowth was visually evaluated. Additionally, 100 μL of each culture was plated onto blood agar plates to confirm regrowth. A positive culture was defined as a treatment failure. The efficacy of treatment against adherent bacteria was expressed as a cure rate (%), defined as the number of cages without growth divided by the total number of cages in each treatment group. Additionally, 0.5 McFarland was achieved using a single colony on a regrowth plate. Each 0.5. 100 μL of McFarland culture was plated onto MHA plates containing the antibiotic corresponding to the treatment used (Note: Bacteria from mice treated with Debio 1450 were plated onto plates containing Debio 1452). Growth conditions are as shown in Table 3 below.

[0440] [Table 3]

[0441]

[0442] Debio 1450 BES alone, 3.81±1.15 log from baseline 10 It showed a reduction in adherent bacteria by CFU / mL (mean ± SD, n=3) and a 50% cure rate (n=6), exhibiting only a moderate anti-biofilm effect (Table 4 and Fig. 3). For the DAP antibiotic, 3.91 ± 0.98 log 10 A reduction in CFU / mL (n=3) and a cure rate of 33% (n=6) were observed. As expected from known anti-biofilm effects, rifampicin was the most active among the tested monotherapys (3.37±0 log). 10 CFU / mL (n=3) and cure rate 100% (n=5)).

[0443] The Debio 1450 BES / daptomycin combination showed enhanced activity compared to the two compounds alone, targeting biofilms at 4.48±0 log 10 It reduced levels to CFU / mL (n=3) and eradicated infection in 83% of animals (n=6, treatment failure was observed in only one animal). The anti-biofilm activity of the Debio 1450 BES / daptomycin combination was comparable to standard rifampicin / daptomycin treatment (biofilm reduction 4.48±0 log). 10CFU / mL (n=3) and a cure rate of 100% (n=5) were similar. On day 9, adherent bacterial levels were significantly lower in animals treated with Debio 1450 BES / daptomycin (p=0.0044, n=6, Kruskal-Wallis and Dunn's tests), rifampicin / daptomycin (p=0.0014, n=5), and rifampicin (p=0.0014, n=5) compared to the vehicle group.

[0444] Results of the investigation into airborne bacteria showed that rifampicin and daptomycin monotherapy and combination therapy demonstrated a bactericidal effect (i.e., average reduction in bacterial load ≥3Log) on ​​day 3 (i.e., 2 days after treatment). 10 While ) was shown, Debio 1450 BES and Debio 1450 BES / Daptomycin were shown on day 6 (i.e., 5 days after treatment). Since additional time points between day 1 and day 6 were not evaluated, the exact time course of the bactericidal effect cannot be inferred. The results are summarized in Table 4 below.

[0445] [Table 4]

[0446] Effect of antibiotic treatment on suspending and adherent bacteria. The reduction in suspending and adherent bacterial fractions from baseline (day 1, before treatment) was determined by plating tissue cage fluid (days 1, 3, 6, and 9) and explanted tissue cage media after sonication (days 1 and 9). Adherent bacterial regrowth and cure rates after sonication were indicated. nt = not tested.

[0447]

[0448] Figure 3 is a graphical representation of the results. In vitro investigation of in vivo treatment-induced resistance showed no decrease in susceptibility for each antibiotic used as monotherapy or in combination.

[0449] In summary, the anti-biofilm activity of the Debio 1450 BES / daptomycin combination obtained in this study, which is similar to the standard rifampicin / daptomycin treatment, reaffirms the data observed in a mouse catheter-associated biofilm infection model (e.g., Example 1 above).

[0450] 6.3. Example 3: Efficacy of Debio 1450 BES in a Mouse Tissue Cage Model of MRSA Infection

[0451] The purpose of this study was to evaluate the efficacy of Debio 1450 BES alone and in combination with daptomycin (DAP) in a mouse tissue cage model of implant-associated infection induced by methicillin-resistant Staphylococcus (S.) aureus (MRSA) at lower doses and longer treatment durations than those used in the previous study (Example 2). The efficacy against a 24-hour biofilm of S. aureus ATCC 43300 (MRSA) was investigated. Using a small initial inoculum (ca. 300 CFU / cage) with a 24-hour biofilm can simulate the clinical setting of acute implant infection and / or surgical necrotic tissue removal.

[0452] The Debio 1450 BES dose of 20 mg / kg BID reflects the latest HED of 240 mg BID obtained from a recent PK study (50 mg / kg BID was used in Example 2 based on previous PK analysis). The dose of daptomycin was also reduced from 100 mg / kg qdam (Example 2) to 50 mg / kg qdam, which is the dose previously used in this model and represents a lower clinically recommended dose range. A treatment period of 11 days was selected to compensate for the dose reduction of Debio 1450 BES (5.5 days of treatment were used in Example 2) and corresponds to long-term antibiotic treatment applied to patients with prosthetic joint infections.

[0453] The same mouse tissue cage model was used as described in Example 2 above. Animals received antibiotic treatment in ip from day 1 to day 11 after infection. One group received only 5% glucose and was used as an infected untreated control (vehicle). The treatment duration and antibiotic dosage were selected to better compare the results of this study with the study in Example 1 (mouse catheter-associated biofilm infection model), in which the Debio 1450 BES (50 mg / kg) / DAP (120 mg / kg) combination showed a 42% cure rate against 24-hour MRSA biofilms. Debio 1450 BES and vehicle were administered bid, and DAP was administered qdam. In this study, we investigated the efficacy of lower doses over a long treatment period.

[0454] The sterility of the transplanted cages was confirmed by aspirating TCF and plating it on blood agar plates 5 to 6 days prior to infection. To confirm the establishment of infection, TCF was aspirated and plated on day 1 (before treatment). Additionally, the number of bacteria in the TCF was measured on day 3 (the day before the first injection), days 6, 9, and 11 (before final treatment), and day 14 (before cage transplantation) to evaluate therapeutic efficacy against free-floating bacteria. The number of mice and bacteria in a given cage was reported to analyze the time course of the antimicrobial activity of the test drug. Efficacy against biofilm-gut bacteria was evaluated qualitatively and quantitatively after sterile transplantation of tissue cages 3 days after the completion of treatment. A 3-day rest period helped to avoid antibiotic carryover effects. For explantation, the cages were washed twice with phosphate-buffered saline (PBS) (Lot 5060914) and immediately transferred to 5 mL of 0.9% NaCl (Lot L171095). The number of bacteria dispersed in the biofilm was determined by plating after 30 seconds of vortexing, sonication (3 minutes at 130 W), and an additional 30 seconds of vortexing. The sonicated cages were washed once with PBS, transferred to 5 mL of TSB (Lot 0286463), and incubated at 37°C for 48 hours, followed by an additional vortexing step after 24 hours of incubation. After incubation, the tubes were vortexed again, and bacterial regrowth was visually evaluated. Additionally, 100 μL of each culture was plated onto blood agar plates to confirm regrowth. A positive culture was defined as a treatment failure. The efficacy of treatment against adherent bacteria was expressed as a cure rate (%), defined as the number of cages without growth divided by the total number of cages in each treatment group. Additionally, 0.5 McFarland was achieved using a single colony on a regrowth plate. Each 0.5. 100 μL of McFarland culture was plated onto MHA plates containing the antibiotic corresponding to the treatment used (Note: Bacteria from mice treated with Debio 1450 were plated onto plates containing Debio 1452). Growth conditions are as shown in Table 5 below.

[0455] [Table 5]

[0456]

[0457] Debio 1450 BES alone, 4.35±2.5 log from baseline 10 It demonstrated an excellent anti-biofilm effect, showing a reduction in adherent bacteria by CFU / mL (mean ± SD) and an 83% cure rate (n=6) (Table 6 and Fig. 4). Consistent with previous reports on the activity of daptomycin in this model, daptomycin showed 3.15 ± 2.74 log 10 A decrease in CFU / mL and a cure rate of 50% (n=6) were observed. The Debio 1450 BES / daptomycin combination showed enhanced activity compared to the two compounds alone, targeting biofilms at 5.13±0.99 log 10 It reduced levels to CFU / mL and eradicated infection in 100% of animals (n=6). This cure rate was slightly higher than in the study of Example 2, where Debio 1450 BES, daptomycin monotherapy, and the Debio 1450 BES / daptomycin combination eradicated infection in 50%, 33%, and 83% (n=6) of animals, respectively. Compared to the vehicle group, adherent bacterial levels at day 14 were slightly lower in animals treated with Debio 1450 BES (p=0.0069, n=6, Kruskal-Wallis and Dunn's tests) and Debio 1450 BES / daptomycin (p=0.0011, n=6), but not with daptomycin (p=0.00631, n=6).

[0458] As a result of the investigation into airborne bacteria, monotherapy and combination therapy with Debio 1450 BES and daptomycin showed a bactericidal effect (i.e., mean reduction in bacterial load ≥3Log) on ​​day 6 (i.e., after 5 days of treatment). 10 ...was shown. Since additional time points between day 1 and day 6 were not evaluated, the exact time course of the sterilization effect cannot be inferred.

[0459] [Table 6]

[0460] Effect of antibiotic treatment on buoyant and attached bacteria. The reduction in buoyant and attached bacterial fractions from baseline (day 1, before treatment) was determined by plating tissue cage fluid (days 1, 3, 6, 9, 11, and 14) and explanted tissue cage media after sonication (days 1 and 9). The reduction in plankton and attached bacterial fractions from baseline (day 1, before treatment) was determined by plating tissue cage fluid (days 1, 3, 6, 9, 11, and 14) and explanted tissue cage media after sonication (days 1 and 14). Attached bacterial regrowth and cure rates after sonication were indicated.

[0461]

[0462] Figure 4 is a graphical representation of the results. In vitro investigation of in vivo treatment-induced resistance showed no decrease in susceptibility to each antibiotic used.

[0463] In summary, the anti-biofilm activity of the Debio 1450 BES / daptomycin combination obtained in this study reaffirms the data observed in the study using this model as described in Example 2 above and the study using the mouse catheter-associated biofilm infection model described in Example 1 above.

[0464] 6.4. Example 4: Efficacy of Debio 1450 BES in a Mouse Tissue Cage Model of Staphylococcus Biofilm Infection

[0465] The purpose of this study was to evaluate the efficacy of Debio 1450 BES in combination with clindamycin or vancomycin and to compare it with the corresponding combination with rifampicin using a mouse tissue cage model of implant-associated infection. The efficacy of the combination with clindamycin and the combination with vancomycin against 24-hour biofilms of S. aureus ATCC 29213 (methicillin-susceptible S. aureus [MSSA]) and S. aureus ATCC 43300 (MRSA), respectively, was tested. The same mouse tissue cage model described in Example 3 was used. Animals were treated with antibiotics according to the regimen indicated in Table 7 from day 1 to day 11 after infection (i.e., 11-day treatment). Efficacy against biofilm-gut bacteria was quantitatively evaluated 3 days after the completion of treatment, following aseptic transplantation into the tissue cage. Upon ex-situation, the cages were washed twice with phosphate-buffered saline (PBS) and immediately transferred to 5 mL of 0.9% NaCl. After 30 seconds of vortexing, sonication (3 minutes at 130 W), and an additional 30 seconds of vortexing, the sonicated cages were washed once with PBS, transferred to 5 mL of TSB, and incubated at 37°C for 48 hours, followed by an additional vortexing step after 24 hours of incubation. After incubation, the tubes were vortexed again, and bacterial regrowth was visually assessed. A positive culture was defined as a treatment failure. The efficacy of the treatment against adherent bacteria was expressed as a cure rate (%), defined as the number of growth-free cages divided by the total number of cages in each individual treatment group.

[0466] The results are summarized in Table 7. The anti-biofilm activity (expressed as cure rate (%)) of the Debio 1450 BES / clindamycin and Debio 1450 BES / vancomycin combinations was similar to that of the rifampicin / clindamycin and rifampicin / vancomycin combinations, respectively.

[0467] [Table 7]

[0468] Summary of cure rates after 11 days of treatment with 24-hour Staphylococcus biofilms in a mouse tissue cage model. Staphylococcus regrowth in the transplanted tissue cages was determined on day 14 (i.e., 3 days after the end of treatment). Positive bacterial cultures were defined as treatment failure. The efficacy of treatment against adherent bacteria was expressed as a cure rate (%), defined as the number of cages without growth divided by the total number of cages in each individual treatment group.

[0469]

Claims

Claim 1 A pharmaceutical composition for use in a method for treating a bacterial infection associated with a biofilm, comprising afabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof, wherein the method comprises administering afabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof to a patient in combination with one or more additional agents selected from the group consisting of lipopeptide, glycopeptide, and lincosamide, or pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof, wherein the lipopeptide is daptomycin, the glycopeptide is vancomycin, the lincosamide is clindamycin, and the biofilm is Staphylococcus ( staphylococcus A pharmaceutical composition containing or composed of bacteria. Claim 2 A pharmaceutical composition according to claim 1, wherein the method comprises administering apabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof in combination with daptomycin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof to a patient. Claim 3 In paragraph 1, Staphylococcus ( staphylococcus ) Bacteria selected from the group consisting of: - Staphylococcus aureus, including community-acquired and hospital-acquired Staphylococcus aureus; - Coagulase-negative Staphylococci (CoNS); or - Coagulase-negative Staphylococcus epidermidis, Staphylococcus haemolyticus, Staphylococcus lugdunensis, Staphylococcus simulans; or Staphylococcus hominis - methicillin-susceptible or Methicillin-resistant Staphylococcus, Staphylococcus aureus, or Staphylococcus epidermidis, comprising - Staphylococcus aureus strain or CoNS strain or Staphylococcus epidermidis, wherein said strain is resistant to one or more antibiotics or is resistant to one or more antibiotics selected from β-lactam, cephalosporin, vancomycin, glycopeptide, linezolid, clindamycin, lincosamide, rifampicin, daptomycin, lipopeptide, fluoroquinolone, trimethoprim / sulfamethoxazole, phosphomycin, fusidic acid, tigecycline, tetracycline, and dalbavancin, - multidrug-resistant Staphylococcus strain, multidrug-resistant Staphylococcus aureus strain, multidrug-resistant CoNS strain, or multidrug-resistant Staphylococcus A pharmaceutical composition in which the Staphylococcus bacteria is Staphylococcus aureus and / or CoNS and / or Staphylococcus epidermidis. Claim 4 A pharmaceutical composition according to claim 1, wherein the bacterial infection is associated with a wound at an open wound and / or wet wound and / or a site with drainage. Claim 5 A pharmaceutical composition according to claim 1, wherein apabicin or its pharmaceutically acceptable salt, hydrate, solvate, or polymorph in combination with one or more additional agents is administered during the perioperative period or before and / or after surgery. Claim 6 A pharmaceutical composition according to claim 1, wherein the bacterial infection is associated with a biofilm containing Staphylococcus bacteria resistant to rifampicin. Claim 7 A pharmaceutical composition according to claim 1, comprising a biofilm containing Staphylococcus aureus, Staphylococcus aureus, CoNS, or Staphylococcus epidermidis, in which the bacterial infection is methicillin-resistant. Claim 8 The pharmaceutical composition of claim 1, wherein the bacterial infection is selected from the group consisting of: - infection associated with a medical implant, - osteomyelitis, - infection in a patient with cystic fibrosis, - pleurolary infection, pneumonia, chronic pleurolary infection, or obstructive pulmonary disease, - endocarditis, or native valve endocarditis, - wound infection, or chronic infection, - mastitis, - sinusitis, or chronic sinusitis, - otitis media, or chronic otitis media, - urinary tract infection, - tonsillitis, or chronic tonsillitis, - laryngitis, or chronic laryngitis, - infection associated with kidney stones, - biliary tract infection, - aerobic vaginitis, - septic thrombophlebitis, - infection associated with intracellular biofilm, or infection associated with intracellular biofilm in Kupffer cells or tonsil cells, and - colonization by Staphylococcus aureus to which the patient is susceptible. Claim 9 A pharmaceutical composition according to claim 1, wherein the bacterial infection is a medical implant-associated infection and the medical implant is a permanent indwelling device or an artificial joint. Claim 10 A pharmaceutical composition according to claim 1, wherein the bacterial infection is a medical implant-associated infection, a catheter-associated infection, an endotracheal tube-associated infection, a voice prostheses-associated infection, or a soft tissue filler-associated infection, and said soft tissue filler may be permanent or semi-permanent. Claim 11 A pharmaceutical composition according to claim 1, wherein the method comprises a debridement step in addition to the administration of apabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof combined with one or more additional agents. Claim 12 A pharmaceutical composition according to claim 8, wherein the method comprises the step of exchanging a medical implant in addition to administering apabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof combined with one or more additional agents. Claim 13 A pharmaceutical composition according to claim 12, wherein the step of administering apabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof in combination with one or more additional agents is performed before or after the step of replacing the medical implant, or said administration is performed before and after the step of replacing the medical implant. Claim 14 A pharmaceutical composition according to claim 1, wherein apabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof is administered intravenously, orally, parenterally, and / or topically and / or transdermally. Claim 15 A pharmaceutical composition according to claim 1, wherein apabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof is administered intravenously in the first step and orally in the second step. Claim 16 A pharmaceutical composition according to claim 1, wherein one or more additional preparations are administered orally, parenterally, transdermally, intravenously, and / or topically. Claim 17 A pharmaceutical composition according to claim 12, wherein the method comprises: a first step of removing a medical implant; a second step of intravenously administering apabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof in combination with one or more additional agents; a third step of introducing a new medical implant; a fourth step of intravenously administering apabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof in combination with one or more additional agents; and a fifth step of orally administering apabicin or a pharmaceutically acceptable salt, hydrate, solvate, or polymorph thereof in combination with one or more additional agents. Claim 18 Staphylococcus (including Daptomycin or its pharmaceutically acceptable salts, hydrates, solvates, or polymorphs) in combination with Afabicin or its pharmaceutically acceptable salts, hydrates, solvates, or polymorphs staphylococcus A pharmaceutical composition for use in a method of treating bacterial infections associated with biofilms containing bacteria. Claim 19 Staphylococcus (including vancomycin or its pharmaceutically acceptable salts, hydrates, solvates, or polymorphs) in combination with afabicin or its pharmaceutically acceptable salts, hydrates, solvates, or polymorphs staphylococcus A pharmaceutical composition for use in a method of treating bacterial infections associated with biofilms containing bacteria. Claim 20 Staphylococcus (composed of clindamycin or its pharmaceutically acceptable salts, hydrates, solvates, or polymorphs) in combination with afabicin or its pharmaceutically acceptable salts, hydrates, solvates, or polymorphs staphylococcus A pharmaceutical composition for use in a method of treating bacterial infections associated with biofilms containing bacteria. Claim 21 Staphylococcus (comprising afabicin or its pharmaceutically acceptable salts, hydrates, solvates, or polymorphs, and one or more additional agents selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, or their pharmaceutically acceptable salts, hydrates, solvates, or polymorphs) staphylococcus A pharmaceutical composition for use in a method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the lipopeptide is daptomycin, the glycopeptide is vancomycin, and the lincosamide is clindamycin. Claim 22 Staphylococcus (comprising afabicin or its pharmaceutically acceptable salts, hydrates, solvates, or polymorphs, and one or more additional agents selected from the group consisting of lipopeptides, glycopeptides, and lincosamides, or their pharmaceutically acceptable salts, hydrates, solvates, or polymorphs) staphylococcus A kit for use in a method for treating a bacterial infection associated with a biofilm containing bacteria, wherein the lipopeptide is daptomycin, the glycopeptide is vancomycin, and the lincosamide is clindamycin. Claim 23 delete Claim 24 delete Claim 25 delete Claim 26 delete Claim 27 delete Claim 28 delete

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