Compositions of bedaquiline, combinations containing them, processes for preparing them, uses and methods of treatment containing them

Abstract

The present invention relates to pharmaceutical compositions for inhalation comprising a therapeutically effective amount of bedaquiline, provided in the form of a suspension or in the form of a dry powder, and methods for preparing them. Furthermore, the present invention provides pharmaceutical combinations comprising bedaquiline in the form of an aerosol for pulmonary inhalation. The combinations and compositions provided by the present invention may be used in the treatment and / or prevention of pulmonary infections caused by Mycobacteria and other Gram-positive bacteria.

Description

[Technical field]

[0001] This application claims priority to U.S. Provisional Patent Application No. 62 / 778,953, filed December 13, 2018, the contents of which are incorporated herein by reference.

[0002] The present invention relates to pharmaceutical compositions for inhalation comprising a therapeutically effective amount of bedaquiline, provided in the form of a suspension or as a dry powder, to processes for their preparation, and to uses and methods of treatment comprising them. Furthermore, the present invention provides a pharmaceutical combination comprising bedaquiline in the form of an aerosol for pulmonary inhalation.

[0003] The combinations and compositions provided by the present invention may be used in the treatment and / or prevention of pulmonary infections caused by mycobacteria and other gram-positive bacteria. [Background technology]

[0004] Janssen Pharmaceutica (a subsidiary of J&J) discovered bedaquiline (initially called TMC207) around 2002 while screening for compounds that would kill Mycobacterium smegmatis, a saprophytic distant relative of Mycobacterium tuberculosis. Bedaquiline (BDQ) emerged from a whole-cell screen of 70,000 library compounds against non-pathogenic M. smegmatis strains of TB (see, e.g., Guillemont, J., Meyer, C., Poncelet, A., Bourdrez, X. and Andries, K., “Diarylquinolines, synthesis pathways and quantitative structure-activity relationship studies leading to the discovery of TMC207”, Future Medicinal Chemistry (2011), 3: pp. 1345-1360), where a racemic mixture (containing four diastereomers) was shown to have useful activity against both M. smegmatis and M. tuberculosis, with the R,S enantiomer being the most potent. Bedaquiline (sold under the trade name Sirturo™) belongs to a class of compounds known as diarylquinolines (DARQs), also called substituted quinoline derivatives.

[0005] The chemical name for bedaquiline is · 3-Quinolineethanol, 6-bromo-α-[2-(dimethylamino)ethyl]-2-methoxy-α-1-naphthalenyl-β-phenyl-, (αS,βR)-; and (1R,2S)-1-(6-bromo-2-methoxyquinolin-3-yl)-4-(dimethylamino)-2-(naphthalen-1-yl)-1-phenylbutan-2-ol Includes.

[0006] The structure of bedaquiline (BDQ) is shown below. [ka]

[0007] Structurally and mechanistically, DARQs are distinct from both the fluoroquinolones (including methoxyquinolines) and other quinoline classes (see, e.g., Andries, K., Verhasselt, P., Guillemont, J., Goehlmann, HWH., Neefs, JM., Winkler, H., Van Gestel, J., Timmerman, P., Zhu, M., Lee, E., Williams, P., de Chaffoy, D., Huitric, E., Hoffner, S., Cambau, E., Truffot-Pernot, C., Lounis, N. and Jarlier, V., “A diarylquinoline drug active on the ATP synthase of Mycobacterium tuberculosis”, Science (2005), 307:pp. 223-227). In vitro studies have demonstrated that bedaquiline provides a novel mechanism of antitubercular action by specifically inhibiting mycobacterial adenosine triphosphate (ATP) synthase.

[0008] Bedaquiline is also very lipophilic (logP 7.25 was measured), which may contribute to its induction of phospholipidosis, which is seen at high doses in preclinical models (see, e.g., Mesens, N., Verbeeck, J., Rouan, M. and Vanparys, P., “Elucidating the role of M2 in the preclinical safety profile of TMC207. In Abstract on the 38th Union World Conference on Lung Health, Cape Town, South Africa, 2007). Its high lipophilicity may also contribute to bedaquiline's long terminal elimination half-life (see, e.g., Svensson, EM., Murray, S., Karlsson, MO. and Dooley, KE., “Rifampicin and rifapentine significantly reduce concentrations of bedaquiline, a new anti-TB drug”, Journal of Antimicrobial See Chemotherapy (2015), 70: pp. 1106-1114), which at high doses or with daily administration can result in overproportional accumulation in tissues. More significantly, bedaquiline has been shown to potently inhibit drug-susceptible, multidrug-resistant and latent tuberculosis, and is the first drug to be approved by the Food and Drug Administration for the treatment of tuberculosis in 40 years.

[0009] An impressive Phase IIb clinical trial demonstrated that the addition of bedaquiline to a tuberculosis treatment regimen significantly improved cure rates, reduced relapse rates, and reduced duration of treatment compared to standard regimens alone (e.g., Diacon, AH., Pym, A., Grobusch, M., Patientia, R., Rustomjee, R., Page-Shipp, L., Pistorius, C., Krause, R., Bogoshi, M., Churchyard, G., Venter, A., Allen, J., Palomino, JC., De Marez, T., van Heeswijk, R.G., Lounis, N., Meyvisch, P., Verbeeck, J., Parys, W., de Beule, K., Andries, K. and Mc Neeley, D.F., “The Diarylquinoline TMC207 for Multidrug-Resistant Tuberculosis”, The New England Journal of Medicine(2009), 360:pp.2397-2405;Diacon, AH., Dawson, R., von Groote-Bidlingmaier, F., Symons, G., Venter, A., Donald, PR., van Niekerk, C., Everitt, D., Winter, H., Becker, P., Mendel, CM. and Spigelman, MK., “14-day bactericidal activity of PA-824, bedaquiline, pyrazinamide, and moxifloxacin combinations: a randomized trial”, The Lancet(2012),380(9846):pp.986-993;Pym,AS.,Diacon,AH.,Tang,SJ.,Conradie,F.,Danilovits,M.,Chuchottaworn,C.,Vasilyeva,I.,Andries,K.,Bakare,N.,De Marez, T., Haxaire-Theeuwes, M., Lounis, N., Meyvisch, P., Van Baelen, B., van Heeswijk, RPG. and Dannemann, B.(See “Bedaquiline in the treatment of multidrug-and extensively drug-resistant tuberculosis”, The European Respiratory Journal (2016), 47(2):pp.564-574). Importantly, Bedaquiline retains clinical activity against drug-susceptible, multidrug-resistant, and extensively drug-resistant TB.

[0010] The antibacterial activity of bedaquiline (Soni, I., De Groote, MA., Dasgupta, A. and Chopra, S., “Challenges facing the drug discovery pipeline for non-tuberculous mycobacteria”, Journal of Medical Microbiology (2016), 65: pp. 1-8) is unique among antibiotics due to its specificity and potency against mycobacteria alone by inhibiting mycobacterial ATP synthase (Koul, A., Dendouga, N., Vergauwen, K., Molenberghs, B., Vranckx, L., Willebrords, R., Ristic, Z., Lill, H., Dorange, I., Guillemont, J., Bald, D. and Andries, K., “Diarylquinolines target subunit c of mycobacterial ATP synthase”, Nature Chemical Biology(2007),3:pp.323-324). Indeed, Andries et al. showed that the minimum inhibitory concentration (MIC)99 of bedaquiline was between 0.01 and 0.1 μg / ml against a variety of Mycobacterium tuberculosis isolates, independent of resistance to other commonly used anti-TB drugs (Andries, K., Verhasselt, P., Guillemont, J., Goehlmann, H. W. H., Neefs, J. M., Winkler, H., Van Gestel, J., Timmerman, P., Zhu, M., Lee, E., Williams, P., de Chaffoy, D., Huitric, E., Hoffner, S., Cambau, E., Truffot-Pernot, C., Lounis, N. and Jarlier, V., “A diarylquinoline drug active on the ATP synthase of Mycobacterium tuberculosis” in tuberculosis”, Science(2005), 307:pp.223-227. These results were reproduced using a standardized broth dilution assay, with demonstrated MICs ranging between 0.015 and 0.12 μg / ml against Mycobacterium tuberculosis H37Rv (Kaniga, K., Cirillo, D. M., Hoffner, S., Ismail, N. A., Kaur, D., Lounis, N., Metchock, B., Pfyffer, G. E. and Venter, A., “A Multilaboratory, Multicountry Study To Determine Bedaquiline MIC Quality Control Ranges for Phenotypic Drug Susceptibility Testing”, Journal of Clinical Microbiology (2016), 54(12): pp. 2956-2962. Interestingly, this activity extends to other mycobacteria, including both M. avium and M. abscessus (MIC99 of 0.01-0.03 μg / ml and 0.25-0.5 μg / ml, respectively). This activity has been translated to in vivo models, improving bacterial clearance in models of M. tuberculosis and M. abscessus infection (Obregon-Henao, A., Arnett, K. A., Henao-Tamayo, M., Massoudi, L., Creissen, E., Andries, K., Lenaerts, AJ. And Ordway, DJ., “Susceptibility of Mycobacterium abscessus to Antimycobacterial Drugs in Preclinical Models”, Antimicrobial Agents and Chemotherapy(2015), 59(11):pp.6904-6912; Tasneen, R., Li, SY., Peloquin, CA., Taylor, D., Williams, KN., Andries, K., Mdluli, KE. and Nuermberger, EL., “Sterilizing Activity of Novel TMC207- and PA-824-Containing Regimens in a Murine Model of Tuberculosis”, Antimicrobial Agents and Chemotherapy (2011), 55(12); pp. 5485-5492). Furthermore, the sterilizing activity of BDQ can act synergistically with numerous anti-TB drugs, such as ethambutol, pyrazinamide, linezolid, and clofazimine (Obregon-Henao, A., Arnett, KA., Henao-Tamayo, M., Massoudi, L., Creissen, E., Andries, K., Lenaerts, AJ.And Ordway, DJ., “Susceptibility of Mycobacterium abscessus to Antimycobacterial Drugs in Preclinical Models”, Antimicrobial Agents and Chemotherapy (2015), 59(11): pp. 6904-6912; Reddy, V. M., Einck, L., Andries, K.and Nacy, C. A., “In Vitro Interactions between New Antitubercular Drug Candidates SQ109 and TMC207”, Antimicrobial Agents and Chemotherapy (2015), 59(11): pp. 6904-6912). Chemotherapy(2010), 54(7):pp.2840-2846;Tasneen, R., Williams, K., Amoabeng, O., Minkowski, A., Mdluli, KE., Upton, AM. and Nuermberger, EL., “Contribution of the Nitroimidazoles PA-824 and TBA-354 to the Activity of Novel Regimens in Murine Models of Tuberculosis”, Antimicrobial Agents and Chemotherapy(2015), 59(1):pp.129-135; Lamprecht, DA., Finin, PM., Rahman, A.,Cumming,BM.,Russell,SL.,Jonnala,SR.,Adamson,JH.and Steyn,AJC.,“Turning the respiratory flexibility of Mycobacterium tuberculosis against itself”, Nature Communications(2016):DOI:10.1038 / ncomms123. .

[0011] Table 1 shows the MIC values ​​(μg / ml) of bedaquiline against different mycobacteria (Soni, I., De Groote, MA., Dasgupta, A. and Chopra, S., “Challenges facing the drug discovery pipeline for non-tuberculous mycobacteria”, Journal of Medical Microbiology (2016), 65: pp. 1-8).

[0012] [Table 1]

[0013] Currently, BDQ is administered orally, where its maximum plasma concentration is reached 4-6 hours after administration (Andries, K., Verhasselt, P., Guillemont, J., Goehlmann, HWH., Neefs, JM., Winkler, H., Van Gestel, J., Timmerman, P., Zhu, M., Lee, E., Williams, P., de Chaffoy, D., Huitric, E., Hoffner, S., Cambau, E., Truffot-Pernot, C., Lounis, N. and Jarlier, V., “A diarylquinoline drug active on the ATP synthase of Mycobacterium tuberculosis”, Science (2005), 307: pp. 223-227). These serum concentrations are dose proportional, the biological activity of BDQ is concentration dependent, and area under the curve (AUC) measurements are the primary predictors of drug efficacy (Rouan, M. C., Lounis, N., Gevers, T., Dillen, L., Gilissen, R., Raoof, A. and Andries, K., “Pharmacokinetics and Pharmacodynamics of TMC207 and Its N-Desmethyl Metabolite in a Murine Model of Tuberculosis”, Antimicrobial Agents and Chemotherapy (2012), 56(3): pp. 1444-1451).Ingestion of food with BDQ has been shown to improve bioavailability and increase drug AUC by 2-4 fold compared to the fasted state (Diacon, AH., Pym, A., Grobusch, M., Patientia, R., Rustomjee, R., Page-Shipp, L., Pistorius, C., Krause, R., Bogoshi, M., Churchyard, G., Venter, A., Allen, J., Palomino, JC., De Marez, T., van Heeswijk, R.G., Lounis, N., Meyvisch, P., Verbeeck, J., Parys, W., de Beule, K., Andries, K. and Mc Neeley, D.F., “The Diarylquinoline TMC207 for Multidrug-Resistant Tuberculosis”, The New England Journal of Medicine (2009), 360: pp. 2397-2405; van Heeswijk, RPG., Dannemann, B. and Hoetelmans, RMW., “Bedaquiline: a review of human pharmacokinetics and drug-drug interactions”, Journal of Antimicrobial Chemotherapy (2014), 69: pp. 2310-2318).

[0014] Upon administration, bedaquiline shows preferential tissue accumulation in the lungs and spleen, as well as high binding to plasma proteins in serum (Andries, K., Verhasselt, P., Guillemont, J., Goehlmann, HWH., Neefs, JM., Winkler, H., Van Gestel, J., Timmerman, P., Zhu, M., Lee, E., Williams, P., de Chaffoy, D., Huitric, E., Hoffner, S., Cambau, E., Truffot-Pernot, C., Lounis, N. and Jarlier, V., “A diarylquinoline drug active on the ATP synthase of Mycobacterium tuberculosis”, Science (2005), 307: pp. 223-227).In a phase II clinical trial of drug-susceptible TB, BDQ was measured in sputum after 7 days of treatment with 400 mg, with a Cmax of 5 μg / ml, which was comparable to serum concentrations seen with the same treatment regimen (Rustomjee, R., Diacon, AH., Allen, J., Venter, A., Reddy, C., Patientia, RF., Mthiyane, TCP., De Marez, T., van Heeswijk, R., Kerstens, R., Koul, A., De Beule, K., Donald, PR. and McNeeley, DF., “Early Bactericidal Activity and Pharmacokinetics of the Diarylquinoline TMC207 in Treatment of Pulmonary Tuberculosis”, Antimicrobial Agents and Chemotherapy (2008), 52(8): pp. 2831-2835; Lounis, N., Gevers, T., Van Den Berg, J. and Andries, K., “Impact of the Interaction of R207910 with Rifampin on the Treatment of Tuberculosis Studied in the Mouse Model”, Antimicrobial Agents and Chemotherapy(2008), 52(10):pp.3568-3572.This high tissue penetration, along with the extended tissue half-life, results in a long effective half-life of 24 hours and an extended terminal half-life of 5.5 months (Andries, K., Verhasselt, P., Guillemont, J., Goehlmann, HWH., Neefs, JM., Winkler, H., Van Gestel, J., Timmerman, P., Zhu, M., Lee, E., Williams, P., de Chaffoy, D., Huitric, E., Hoffner, S., Cambau, E., Truffot-Pernot, C., Lounis, N. and Jarlier, V., “A diarylquinoline drug active on the ATP synthase of Mycobacterium tuberculosis”, Science (2005), 307: pp. 223-227; Janssen Pharmaceutical Companies, Briefing Document “TMC207(bedaquiline)Treatment of Patient with MDR-TB”, FDA Anti-Infective Drugs Advisory Committee Meeting (November 28, 2012) pp.1-253).

[0015] Despite the benefits of adding BDQ to mycobacterial treatment regimens, adverse events related to treatment are observed. The most commonly affected tissues include liver and cardiac tissue, with QT interval prolongation and electrical rhythm disturbances being the most common for the latter (Kwon, YS.And Koh, WJ.,“Synthetic investigational new drugs for the treatment of tuberculosis”, Expert Opinion on Investigational Drugs(2016),25(2):pp.183-193;Goulooze, SC.,Cohen, AF.and Rissmann, R.,“Bedaquiline“,British Journal of Clinical Pharmacology(2015),80(2):pp.182-184;Kakkar, AK.and Dahiya, N.,“Bedaquiline for the treatment of resistant tuberculosis:promises and pitfalls.”,Tuberculosis(2014),94(4):pp.357-362).Importantly, increased mortality is also associated with current BDQ therapy, but deaths are due to respiratory compromise and not due to BDQ toxicity (Diacon, AH., Pym, A., Grobusch, M.P., de los Rios, J.M., Gotuzzo, E., Vasilyeva, I., Leimane, V., Andries, K., Bakare, N., De Marez, T., Haxaire-Theeuwes, M., Lounis, N., Meyvisch, P., De Paepe, E. and van Heeswijk, R.G., “Multidrug-Resistant Tuberculosis and Culture Conversion with Bedaquiline”, The New England Journal of Medicine(2014),317:pp.723-732;Mingote, LR., Namutamba, D., Apina, F., Barnabas, N., Contreras, C., Elnour, T., Frick, MW., Lee, C., Seaworth, B., Shelly, D., Skipper, N. and dos Santos Filho, ET., “The use of bedaquiline in regimens to treat drug-resistant and drug-susceptible tuberculosis: a perspective from tuberculosis-affected communities”, Lancet (2015), 385:pp.477-479).

[0016] Further concerns have arisen regarding drug-drug interactions of BDQ, particularly over interactions between BDQ and anti-TB drugs and antiviral drugs for the treatment of human immunodeficiency virus (HIV), which has a high rate of co-infection with TB (http: / / apps.who.int / iris / bitstream / 10665 / 191102 / 1;9879241566509eng.pdf) (last accessed 4 January 2018)). In fact, it has been shown that co-treatment of BDQ with rifamycin group antibiotics reduces BDQ AUC by up to 59% due to the ability of rifampicin to induce CYP enzyme activity (van Heeswijk, RPG., Dannemann, B. and Hoetelmans, RMW., “Bedaquiline: a review of human pharmacokinetics and drug-drug interactions”, Journal of Antimicrobial Chemotherapy (2014), 69: pp. 2310-2318). Due to similar interactions with a great number of antiviral drugs, co-administration of BDQ with lopinavir / ritonavir results in decreased antiviral concentrations instead of increased BDQ concentrations. However, it should be noted that many of these studies are single dose interactions, and due to the long residence time of BDQ, more extended treatment studies are required.

[0017] The advantages of pulmonary delivery of antimycobacterial therapy have been reviewed by Das (Das, S., Tucker, I., and Stewart, P., “Inhaled Dry Powder Combinations for Treating Tuberculosis”, Current Drug Delivery (2015), 12: pp. 26-39), e.g.:

[0018] First, the concentration of the drug in the lungs is higher compared to intramuscular administration, which helps to inhibit biofilm formation and reduces the risk of drug resistance.

[0019] The frequency of administration can be reduced because the drug remains in the lungs for a longer period than with intramuscular and intravenous administration.

[0020] Reduced doses of drugs are required for pulmonary delivery compared to oral administration, and reduced toxicity is associated with reduced amounts of drug in the body.

[0021] Improved patient compliance is anticipated due to the reduction in dosage, frequency and duration of treatment.

[0022] Uptake of drug microparticles by alveolar macrophages can reverse "alternative activation" and induce a bactericidal response.

[0023] Pulmonary delivery is suitable for delivery of drugs when optimal drug concentrations at the site of action are difficult to achieve.

[0024] Pulmonary delivery offers advantages for drugs that are poorly water soluble and difficult to formulate for injection.

[0025] The pulmonary route has the advantage of avoiding injections in the case of injectable drugs that require frequent administration over a long period of time.

[0026] Degradation of drugs by the gastrointestinal environment can be avoided by pulmonary administration, for example, rifampicin, which is degradable by the acidic environment of the stomach in the presence of isoniazid, can be administered via the pulmonary route.

[0027] Finally, and of that relevance, pulmonary administration allows for the avoidance of hepatic first-pass metabolism.

[0028] Many of these potential benefits can be achieved by pulmonary administration of bedaquiline, unlike oral administration of bedaquiline. Recall for example bedaquiline, which has low water solubility. During current oral treatment (400 mg once a day for 2 weeks, followed by 200 mg three times a week for 22 weeks), after ingestion of the pill, bedaquiline must first dissolve in gastric juice and then diffuse into the blood. High penetration into the spleen and binding to plasma proteins in the serum reduces the drug available to enter the lungs. After circulation to the lungs, the drug must diffuse into the lung tissue and then into the macrophages where the mycobacteria reside. Due to the extremely low solubility of bedaquiline, this is a very inefficient system and much of the bedaquiline is excreted with the stool. By delivering bedaquiline directly to the lung periphery, it can be taken up directly by the macrophages and act against the mycobacteria. Bypassing the inefficient oral delivery route means that the pulmonary dose will be lower than the oral dose (10 mg to 100 mg, depending on the characteristics of the inhaled administration).

[0029] Bedaquiline has a very long half-life in tissues of over 5 months. The duration of treatment can be reduced compared to oral therapy by depositing bedaquiline directly in lung tissue.

[0030] Therefore, the use of aerosolized bedaquiline in patients with multidrug-resistant or extensively drug-resistant tuberculosis infection should further improve patient outcomes and may shorten the duration of current treatment regimens.

[0031] The group of nontuberculosis mycobacteria (NTM), previously called atypical or widespread mycobacteria, includes more than 150 species. NTM are found widely in nature and can show a wide diversity. They can be detected in soil, ground, and drinking water, as well as in foods such as pasteurized milk or cheese. In general, NTM are considered to be of low pathogenicity. Nevertheless, they can cause severe disease in humans, especially in immunocompromised individuals or those with preexisting pulmonary disease. Currently, NTM are classified according to their growth rate and are divided into slow-growing (SGM) and rapid-growing (RGM) mycobacteria.

[0032] The slow-growing Mycobacterium avium complex (MAC) comprises the species Mycobacterium avium, Mycobacterium chimaera and Mycobacterium intracellulare, among the most important and most frequent pathogenic NTM. They mostly cause pulmonary infections, as do Mycobacterium kansasii, Mycobaceterium malmoense, Mycobacterium xenopi, Mycobacterium simiae, Mycobacterium abscessus, Mycobacterium gordonae, Mycobacterium fortuitum, and Mycobacterium chelonae. Mycobacterium marinum is involved in skin and soft tissue infections such as aquarium granulomas.

[0033] In particular, RGM causes severe, life-threatening chronic lung disease and is responsible for disseminated, often fatal, infections. Infections typically result from contaminated and invasive procedures, including catheters, non-sterile surgical procedures or injections, and implantation of foreign bodies. Exposure to showerheads and Jacuzzis has also been reported as a risk for infection. NTM typically causes opportunistic infections in patients with chronic lung diseases, such as chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), and other immunocompromised patients.

[0034] In recent years, the rapid growing (RGM) Mycobacterium abscessus group strains (Mycobacterium abscessus complex, MABSC), which include the subspecies Mycobacterium abscessus subsp. abscessus (Maabscessus), Mycobacterium abscessus bolletii. and Mycobacterium abscessus massiliense, have emerged as an important human pathogen and are associated with significantly higher mortality rates than any other RGM.

[0035] Mycobacterium abscessus infections in CF patients are particularly problematic because they lead to widespread lung destruction and are often untreatable with failure rates as high as 60-66% (see, for example, Obregon-Henao A et al, Antimicrobial Agents and Chemotherapy, November 2015, Vol59, No11, p.6904-6912; Qvist, T., Pressler, T., Hoiby, N. and Katzenstein, TL., “Shifting paradigms of nontuberculous mycobacteria in cystic fibrosis”, Respiratory Research (2014), 15(1): pp.41-47).

[0036] Human infections with NTM have become increasingly relevant with the emergence of the human acquired immune deficiency syndrome (AIDS) pandemic. Mycobacteria from the Mycobacterium avium complex (MAC) have been identified as a major cause of opportunistic infections in patients infected with the human immunodeficiency virus (HIV).

[0037] Some species of NTM are known to form biofilms. Biofilms are microcolonies of bacteria embedded in an extracellular matrix that provide stability and resistance to the human immune system. Recently, some species of NTM have been shown to form biofilms that enhance resistance to disinfectants and antibacterial agents. Biofilm assembly proceeds through several phases, including reversible attachment, irreversible attachment, bacterial aggregation, organization, and signaling-mediated biofilm formation, and finally dispersal. During this process, bacteria express extracellular polymeric substances (EPS), matrices containing polysaccharides, lipids, and nucleic acids, to form complex three-dimensional structures (see, e.g., Sousa S. et al., International Journal of Mycobacteriology 4 (2015), 36-43). Specifically, mycobacterial EPS is inherently different from other biofilms because mycobacteria do not produce exopolysaccharides (see, for example, Zambrano MM, Kolter R. Mycobacterial biofilms: a greasy way to hold it together. Cell. 2005). Mycobacterial biofilms vary between species but can contain mycolic acids, glycopeptidolipids, mycolyl-diacylglycerol, lipooligosaccharides, lipopeptides, and extracellular DNA (overview and original research from Rose SJ, Babrak LM, Bermudez LE (2015) Mycobacterium avium Possesses Extracellular DNA that Contributes to Biofilm Formation, Structural Integrity, and Tolerance to Antibiotics, PLoS ONE). Assembly within a biofilm is known to enhance resistance to antibacterial agents (see, for example, Faria S. et al., Journal of Pathogens, Vol 2015, Article ID 809014).

[0038] Delivery of aerosolized liposomal amikacin / amikacin solution for inhalation sprayed by jet nebulizer as a novel approach in the treatment of NTM lung infections (Rose S.et al,2014,PLoS ONE,Volume 9,Issue 9,e108703, and Olivier K.et al,Ann Am Thorac SocVol11,No1,pp.30-35) as well as inhalation of dry powder microparticles of anti-TB drugs for pulmonary delivery (Cholo M et al.,J Antimicrob Chemother.2012 Feb;67(2):290-8 and Fourie B.and Nettey O.,2015 Inhalation Magazine,Verma 2013 Antimicrob Agents Chemother). Summary of the Invention [Problem to be solved by the invention]

[0039] Multiple combination regimens with parenteral aminoglycosides, tigecycline, inhaled amikacin after initial treatment with other promising oral antibiotics such as linezolid, delamanid, and bedaquiline, as well as surgical procedures in selected cases, have shown promising results in the treatment of NTM lung disease (Lu Ryu et al.,Tuberc Respir Dis 2016;79:74-84). However, the increasing incidence and prevalence of NTM infections, especially NTM lung disease, and limited treatment options necessitate the development of novel dosage forms / pharmaceutical formulations and combinations that enhance the bioavailability of currently used antibiotics such as bedaquiline. Inhalation may enhance efficacy and reduce adverse effects compared to oral and parenteral therapy.

[0040] The combination of bedaquiline and clofazimine used against Mycobacterium tuberculosis has shown synergy (see, e.g., Cokol, M. et al., “Efficient Measurement and factorization of high-order drug interactions in Mycobacterium tuberculosis”, Sciences Advances 2017:3:e170881, 11 October 2017).

[0041] Bedaquiline has also been shown to have additive effects with amikacin (see, for example, https: / / www.escmid.org / escmid_pulications / escmid_elibrary / material / ?mid=42441).

[0042] The low solubility of bedaquiline in water results in low oral bioavailability and high microbial resistance, further necessitating specific techniques to solubilize and stabilize the formulation drug in a liquid aqueous carrier, e.g., by aerosolization with a nebulizer, to obtain lower lung deposition of the aerosol particles. [Means for solving the problem]

[0043] The present invention provides bedaquiline in the form of a suspension compatible with a suitable nebulizer, or as a dry powder compatible with a dry powder inhaler, thereby generating aerosol particles suitable for providing significantly enhanced delivery of aerosolized bedaquiline to the lower lung (i.e., the bronchi, bronchioles, and alveoli of the mid and lower peripheral lung).

[0044] The present invention provides an aerosol having aerosol particles of a size that facilitates delivery to the alveoli and bronchioles, thereby substantially enhancing the therapeutic effect. The aerodynamic particle size suitable for targeting the alveoli and bronchioles is between 1 and 5 μm. Larger aerosol particles are preferentially deposited in the upper lung, i.e., the bronchi and trachea, and the mouth and pharynx, i.e., the oropharyngeal region. Thus, the inhalation device is adapted to generate an aerosol having a mass median aerodynamic diameter (MMAD) in the range of about 1 to about 5 μm, preferably in the range of about 1 to about 3 μm. In a further embodiment, the particle size distribution is narrow, having a geometric standard deviation (GSD) of less than about 2.5.

[0045] Aerosol dosages, formulations and delivery systems may be selected depending on the particular therapeutic application, as described, for example, in Gonda, I. "Aerosols for delivery of therapeutic and diagnostic agents to the respiratory tract", Critical Reviews in Therapeutic Drug Carrier Systems, 6, 273-314 (1990), and Moren, "Aerosol dosage forms and formulations", Aerosols in Medicine, Principles, Diagnosis and Therapy, Moren, et al., Eds. Elsevier, Amsterdam, 1985. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0046] The present invention is based on the discovery that pulmonary administration of bedaquiline in the form of an aerosol can achieve lower (i.e. deeper) lung deposition of the active drug, thereby significantly enhancing the bioavailability of this extremely hydrophobic BCS class II drug and resulting in significantly enhanced therapeutic efficacy associated with reduced systemic side effects.

[0047] In another aspect, this finding offers improved antibiotic therapy in infections caused by mycobacteria and gram-positive bacteria, particularly pulmonary infections due to NTM, opportunistic infections in CF, COPD and immunocompromised patients, e.g., HIV patients.

[0048] Furthermore, the present invention aims to overcome the systemic side effects of established oral treatment regimes for pulmonary infections due to Gram-positive bacteria, particularly pulmonary TB and NTM infections, as well as to reduce the dose and duration of treatment with bedaquiline.

[0049] It will be understood by one of ordinary skill in the art that the present application also discloses any combination of each of the individual features disclosed herein.

[0050] definition The term "pharmaceutically acceptable salts" refers to salts that retain the biological effectiveness and properties of the compounds of the present invention, and are not biologically or otherwise undesirable. In many cases, the compounds of the present invention may form acid and / or base salts due to the presence of amino and / or carboxyl groups or groups similar thereto. Pharmaceutically acceptable acid addition salts may be formed with inorganic and organic acids. Inorganic acids from which salts may be derived include, for example, hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid, phosphoric acid, and the like. Organic acids from which salts can be derived include, for example, acetic acid, propionic acid, naphtoic acid, oleic acid, palmitic acid, pamoic (embonic) acid, stearic acid, glycolic acid, pyruvic acid, oxalic acid, maleic acid, malonic acid, succinic acid, fumaric acid, tartaric acid, citric acid, ascorbic acid, glucoheptonic acid, glucuronic acid, lactic acid, lactobionic acid, tartaric acid, benzoic acid, cinnamic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid, p-toluenesulfonic acid, salicylic acid, and the like.

[0051] Pharmaceutically acceptable base addition salts can be formed with inorganic and organic bases. Inorganic bases from which salts can be derived include, for example, sodium, potassium, lithium, ammonium, calcium, magnesium, iron, zinc, copper, manganese, aluminum, etc.; particularly preferred are ammonium, potassium, sodium, calcium and magnesium salts. Organic bases from which salts can be derived include, for example, primary, secondary and tertiary amines, substituted amines, such as naturally occurring substituted amines, cyclic amines, basic ion exchange resins, etc., in particular isopropylamine, trimethylamine, diethylamine, triethylamine, tripropylamine, histidine, arginine, lysine, benethamine, N-methyl-glucamine, and ethanolamine. Other acids include dodecylsufuric acid, naphthalene-1,5-disulfonic acid, naphthalene-2-sulfonic acid, and saccharin.

[0052] According to the invention, the use of the fumarate, sulfate, tartrate, citrate and phosphate salts of bedaquiline, as opposed to the free base, is preferred, in particular the fumarate salt of bedaquiline.

[0053] As used herein, the term "pharmaceutically acceptable derivative" of a compound is, for example, a prodrug of said compound. In general, a prodrug is a derivative of a compound that is capable of providing an active form of the compound upon administration. Such derivatives may be, for example, esters or amides of a carboxyl group, carboxyl esters of a hydroxyl group, or phosphate esters of a hydroxyl group.

[0054] "Patient" means a mammal, preferably a human, in need of prevention and / or treatment as described herein.

[0055] "Therapeutically effective amount", "therapeutically effective dose", or "pharmaceutical effective amount" refers to an amount of bedaquiline as disclosed herein that has a therapeutic effect in a patient. A dose of bedaquiline that is useful in treatment is a therapeutically effective amount. Thus, as used herein, a therapeutically effective amount refers to an amount of bedaquiline that produces the desired therapeutic effect as determined by clinical trial results and / or model animal infection studies.

[0056] The amount and daily dose of bedaquiline can be routinely determined by one of skill in the art and will vary depending on several factors, such as the particular microbial strain involved. This amount may further depend on the height, weight, sex, age, and medical history of the patient. If prophylactic treatment, a therapeutically effective amount is an amount that will be effective to prevent microbial infection.

[0057] "Therapeutic effect" includes alleviating to some extent one or more symptoms of infection and curing the infection. "Cure" means that symptoms of active infection are eliminated, for example, total or substantial elimination of excess members of viable microorganisms involved in the infection to a point at or below the threshold of detection by traditional measurements. However, certain long-term or permanent effects of the infection may persist even after a cure is obtained (such as extensive tissue damage). As used herein, "therapeutic effect" is defined as a statistically significant reduction in bacterial load in the host, emergence of resistance, or improvement in symptoms of infection, as measured by human clinical results or animal studies.

[0058] "Treat," "treatment," or "treating," as used herein, refers to the administration of a pharmaceutical composition / formulation to a patient for prophylactic and / or therapeutic purposes.

[0059] The terms "prophylactic treatment" or "prevention" refer to treating a patient who is not yet infected but who is susceptible to or otherwise at risk for a particular infection. The term "therapeutic treatment" refers to administering treatment to a patient who is already suffering from an infection. Thus, in a preferred embodiment, treatment is the administration of a therapeutically effective amount of bedaquiline to a mammal (for either therapeutic or prophylactic purposes).

[0060] Unless otherwise specified herein, the term "inhalation" is meant to refer to oral inhalation into the lungs.

[0061] Unless otherwise specified herein, the term "infection" as used herein is meant to refer to a pulmonary infection.

[0062] Unless otherwise specified, the term "substantially" when used to refer to the purity of a compound indicates that the purity of the compound is 95% or greater pure.

[0063] Unless otherwise specified, the term "suitable particle size" refers to a particle size of bedaquiline provided in a composition or pharmaceutical combination that results in a desired therapeutic effect when administered to a patient.

[0064] Unless otherwise specified, the term "appropriate concentration" refers to the concentration of ingredients in a composition or pharmaceutical combination that provides a pharma- ceutically acceptable composition or combination.

[0065] Pharmaceutical Compositions and Combinations The following water grades are particularly applicable to the present invention: Sterile Purified Water, Sterile Water for Injection, Sterile Water for Irrigation, Sterile Water for Inhalation (USP) and corresponding water grades according to, for example, the European Pharmacopoeia or the National Formulary.

[0066] Aqueous electrolyte solutions such as those used in accordance with the present invention as aqueous liquid carriers may further comprise sodium chloride, potassium chloride, lithium chloride, magnesium chloride, calcium chloride or mixtures thereof.

[0067] The aqueous liquid carrier is preferably an isotonic saline solution (0.9% NaCl, which corresponds to about 150 mM NaCl, preferably 154 mM NaCl).

[0068] Thus, in one embodiment of the present invention, there is provided a pharmaceutical composition comprising: (a) a therapeutically effective amount of bedaquiline or a pharma- ceutically acceptable derivative or salt thereof; (b) a non-ionic surfactant having a hydrophilic-lipophilic balance value of greater than 10; and (c) an aqueous liquid carrier selected from water, isotonic saline, buffered saline and aqueous electrolyte solutions, wherein the bedaquiline or pharma- ceutically acceptable derivative or salt thereof is provided in the form of particles in suspension, and wherein the bedaquiline particles or particles of the pharma- ceutically acceptable salt of bedaquiline have a median size of less than 5 μm and a D90 of less than 6.5 μm. In another embodiment, the particles of bedaquiline, or a pharma- ceutically acceptable salt thereof have a median size of less than 2 μm and a D90 of less than 3 μm.

[0069] In a further embodiment of the invention there is provided a pharmaceutical composition comprising: (a) a therapeutically effective amount of bedaquiline; (b) a non-ionic surfactant having a hydrophilic-lipophilic balance value of greater than 10; and (c) an aqueous liquid carrier selected from water, isotonic saline, buffered saline and aqueous electrolyte solutions, wherein the bedaquiline is provided in the form of particles in suspension, and the bedaquiline particles have a median size of less than 5 μm and a D90 of less than 6.5 μm. In a further embodiment, the bedaquiline particles have a median size of less than 2 μm and a D90 of less than 3 μm.

[0070] In another embodiment of the invention, in the pharmaceutical composition according to any of the above embodiments, the non-ionic surfactant is selected from the group consisting of polysorbate 20 (e.g. Tween® 20, polysorbate 60 (e.g. Tween® 60), polysorbate 80 (e.g. Tween® 80), stearyl alcohol, polyethylene glycol derivatives of hydrogenated castor oil having a hydrophilic-lipophilic equilibrium value of 14 to 16 (e.g. Cremophor® RH40), polyethylene glycol derivatives of hydrogenated castor oil having a hydrophilic-lipophilic equilibrium value of 15 to 17 (e.g. Cremophor® RH 60), sorbitan monolaurate (e.g. Span® 20), sorbitan monopalmitate (e.g. Span® 40), sorbitan monostearate (e.g. Span® 60), polyoxyethylene (20) oleyl ether (e.g. Brij® 020), polyoxyethylene (20) cetyl ether (e.g. Brij® 58), polyoxyethylene (10) cetyl ether (e.g. Brij® C10), polyoxyethylene (10) oleyl ether ( Brij® O10), polyoxyethylene (100) stearyl ether (e.g. Brij® S100), polyoxyethylene (10) stearyl ether (e.g. Brij® S10), polyoxyethylene (20) stearyl ether (e.g. Brij® S20), polyoxyethylene (4) lauryl ether (e.g. Brij® L4), polyoxyethylene (20) cetyl ether (e.g. Brij® 93), polyoxyethylene (2) cetyl ether (e.g. Brij® In particular, the polyoxyl stearate may be selected from polyethylene glycol (20) stearate (e.g. Myrj™ S2), caprylocaproyl polyoxyl-8 glyceride (e.g. Labrasol®), polyethylene glycol (20) stearate (e.g. Myrj™ 49), polyethylene glycol (40) stearate (e.g. Myrj™ S40), polyethylene glycol (100) stearate (e.g. Myrj™ S100), polyethylene glycol (8) stearate (e.g. Myrj™ S8), and polyoxyl 40 stearate (e.g. Myrj™ 52), and mixtures thereof.

[0071] In a preferred embodiment of the present invention, there is provided a pharmaceutical composition according to any of the above embodiments, wherein the non-ionic surfactant is polysorbate 80 and the aqueous liquid carrier is distilled water, hypertonic saline, or isotonic saline. In another preferred embodiment, the hypertonic saline is 1% to 7% (weight / volume) sodium chloride. In another preferred embodiment, the non-ionic surfactant is ultra-pure polysorbate 80 (e.g., Polysorbate 80 (Hx2) from NOF Corporation) and the aqueous liquid carrier is isotonic saline.

[0072] In another embodiment of the invention, in a pharmaceutical composition according to any of the above composition embodiments, the osmolality of the composition is in the range of 200-700 mOsm / kg. In a preferred embodiment, the osmolality of the composition is in the range of 300-400 mOsm / kg.

[0073] In a further embodiment of the invention there is provided a pharmaceutical composition according to any of the above embodiments, wherein the concentration of the non-ionic surfactant is in the range of 0.001% to 5% (v / v) of the total composition and the amount of bedaquiline is in the range of 0.1% to 20% (w / v) of the total composition.

[0074] In a further embodiment of the invention, the pharmaceutical composition according to any of the above composition embodiments is prepared by a process comprising the steps of: (1) homogenizing a suspension of bedaquiline, a non-ionic surfactant and water to obtain a suspension containing bedaquiline of suitable particle size; (2) adjusting the pH of the suspension resulting from (1) to a pH between pH 5.5 and pH 7.5; (3) adjusting the sodium chloride concentration to a suitable concentration; and (4) adjusting the osmolality to a suitable level. In a preferred embodiment, the pH is adjusted to 6.5 and the sodium chloride concentration is 154 mM sodium chloride. In another preferred embodiment, the homogenization in step (1) is carried out by high pressure homogenization, high shear homogenization, wet milling, ultrasonic homogenization, or a combination of such processes. In another preferred embodiment of the invention, the homogenization of bedaquiline is carried out in multiple homogenization steps.

[0075] In another embodiment of the present invention, there is provided a pharmaceutical composition according to any of the above composition embodiments, prepared by a process comprising the steps of: (1) homogenizing a suspension of bedaquiline and a non-aqueous liquid to obtain a suspension containing bedaquiline of suitable particle size; (2) isolating bedaquiline; (3) adding bedaquiline to a non-ionic surfactant and water; (4) adjusting the pH of the suspension resulting from (3) to a pH between pH 5.5 and pH 7.5; and (5) adjusting the sodium chloride concentration to a suitable concentration. In a preferred embodiment, the pH is adjusted to 6.5 and the sodium chloride concentration is 154 mM sodium chloride. In another preferred embodiment, the homogenization in step (1) is carried out by high pressure homogenization, high shear homogenization, wet milling, ultrasonic homogenization, or a combination of such processes. In another preferred embodiment of the present invention, the homogenization of bedaquiline is carried out in multiple homogenization steps.

[0076] In another embodiment, there is provided a pharmaceutical composition according to any of the embodiments of the composition as described above, prepared by a process comprising the steps of: (1) micronizing bedaquiline to obtain bedaquiline of a suitable particle size; (2) adding bedaquiline to a non-ionic surfactant and water; (3) adjusting the pH of the suspension resulting from (2) to a pH between pH 5.5 and pH 7.5; and (4) adjusting the sodium chloride concentration to a suitable concentration. In a preferred embodiment, the pH is adjusted to 6.5 and the sodium chloride concentration is adjusted to 154 mM sodium chloride. In another preferred embodiment, the micronization of bedaquiline is carried out by jet milling, spray drying, ball milling, or supercritical fluid processing. In another preferred embodiment of the invention, the micronization of bedaquiline is carried out in multiple homogenization steps.

[0077] In a further embodiment, there is provided a pharmaceutical composition according to any of the above composition embodiments prepared by a process comprising homogenizing a suspension of bedaquiline in water containing a non-ionic surfactant, a suitable concentration of sodium chloride, and adjusted to a pH between pH 5.5 and pH 7.5 to obtain bedaquiline of suitable particle size. In a preferred embodiment, the pH is adjusted to 6.5 and the sodium chloride concentration is adjusted to 154 mM sodium chloride. In another preferred embodiment, the homogenization in step (1) is carried out by high pressure homogenization, high shear homogenization, wet milling, ultrasonic homogenization, or a combination of such processes. In another preferred embodiment of the invention, homogenization of bedaquiline is carried out in multiple homogenization steps.

[0078] In another embodiment of the invention there is provided a composition prepared by any of the above method embodiments, wherein the bedaquiline of suitable particle size is particles having an average size of less than 5 μm and a D90 of less than 6.5 μm. In a preferred embodiment, the bedaquiline of suitable particle size is particles having an average size of less than 2 μm and a D90 of less than 3 μm.

[0079] In another embodiment of the present invention, there is provided a pharmaceutical combination in the form of an inhalable aerosol prepared by aerosolization of any of the composition embodiments by a nebulizer selected from ultrasonic nebulizers, electrospray nebulizers, vibrating membrane nebulizers, jet nebulizers and mechanical soft mist inhalers, or any of the compositions prepared by any of the above method embodiments, wherein the aerosol particles generated by the nebulizer have a mass median aerodynamic diameter of 1-5 μm. In another embodiment, the inhalable aerosol is intended for deposition in the lower lung. In a further embodiment, the nebulizer exhibits an output rate of 0.1-1.0 ml / min. In another embodiment, the total inhaled volume is between 1 ml and 5 ml. In another embodiment, the pharmaceutical combination is intended for use in the treatment and / or prevention of pulmonary infections caused by mycobacteria or other gram-positive bacteria. In a further embodiment, the infection is caused by a mycobacterium species selected from nontuberculosis mycobacteria and Mycobacterium tuberculosis complex, and combinations thereof. In a further embodiment, the nontuberculosis mycobacteria is selected from Mycobacterium avium, Mycobacterium intracellulare, Mycobacterium abscessus, and Mycobacterium leprae, and combinations thereof. In another embodiment, the infection is an opportunistic infection selected from MAC pulmonary disease and nontuberculous infections in patients with cystic fibrosis, chronic obstructive pulmonary disease, or acquired immune deficiency syndrome. In another embodiment, the infection is a nontuberculous opportunistic mycobacterial infection in a patient with cystic fibrosis.In a further embodiment, there is provided a pharmaceutical combination to be used as described above, wherein the pharmaceutical combination is used for administration prior to, concurrently with or subsequent to administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. In a further embodiment, the drug is clofazimine. In a further embodiment, the drug is amikacin.

[0080] In another embodiment of the invention, any of the composition embodiments, or any of the compositions prepared by any of the method embodiments above, are combined with an agent for dispersing and / or disrupting biofilms, a mucolytic and / or mucoactive agent, and / or an agent that reduces biofilm formation selected from nebulized 4-7% hypertonic saline, metaperiodic acid, sodium dodecyl sulfate, sodium bicarbonate, tromethamine, silver nanoparticles, bismuth thiol, ethylenediaminetetraacetic acid, gentamicin-loaded phosphatidylcholine modified gold nanoparticles, a chelating agent, cis-2-decenoic acid, D-amino acids, D-enantiomeric peptides, gallium mesoporphyrin IX, gallium protoporphyrin IX, curcumin, patulin, penicillic acid, baicalein, naringenin, ursolic acid, asiatic acid, corosolic acid, fatty acids, host defense peptides, and antimicrobial peptides. In another embodiment, the composition is administered prior to, concurrently with, or subsequent to administration of an agent selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. In a further embodiment, the agent is clofazimine. In a further embodiment, the agent is amikacin.

[0081] In another embodiment, there is provided a pharmaceutical combination to be used in combination with an agent for dispersing and / or disrupting biofilms, a mucolytic and / or mucoactive agent, and / or an agent that reduces biofilm formation selected from nebulized 4-7% hypertonic saline, metaperiodic acid, sodium dodecyl sulfate, sodium bicarbonate, tromethamine, silver nanoparticles, bismuth thiol, ethylenediaminetetraacetic acid, gentamicin-loaded phosphatidylcholine modified gold nanoparticles, chelating agents, cis-2-decenoic acid, D-amino acids, D-enantiomeric peptides, gallium mesoporphyrin IX, gallium protoporphyrin IX, curcumin, patulin, penicillic acid, baicalein, naringenin, ursolic acid, asiatic acid, corosolic acid, fatty acids, host defense peptides, and antimicrobial peptides. In a further embodiment, there is provided a pharmaceutical combination to be used as described above, wherein the pharmaceutical combination is used for administration prior to, concurrently with or subsequent to administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. In a further embodiment, the drug is clofazimine. In a further embodiment, the drug is amikacin.

[0082] In another embodiment of the present invention, any of the pharmaceutical compositions according to any of the composition embodiments or compositions prepared by any of the above method embodiments are provided for use in the treatment and / or prevention of pulmonary infections caused by mycobacteria or other Gram-positive bacteria. In a further embodiment, the infection is caused by a mycobacterium species selected from nontuberculosis mycobacteria and Mycobacterium tuberculosis complex, and combinations thereof. In another embodiment, the nontuberculosis mycobacteria is selected from Mycobacterium avium, Mycobacterium intracellulare, Mycobacterium abscessus, and Mycobacterium leprae, and combinations thereof. In a further embodiment, the infection is an opportunistic infection selected from MAC pulmonary disease and nontuberculous infections in patients with cystic fibrosis, chronic obstructive pulmonary disease, or acquired immune deficiency syndrome. In another embodiment, the infection is a nontuberculous opportunistic mycobacterial infection in patients with cystic fibrosis. In a further embodiment, the pharmaceutical composition contemplated for the above use is administered prior to, simultaneously with, or subsequent to administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. In a further embodiment, the drug is clofazimine. In a further embodiment, the drug is amikacin.

[0083] In a further embodiment of the present invention, there is provided a system intended for use in demonstrating antibiotic activity in treating or providing prophylaxis against pulmonary infections caused by mycobacteria or other gram-positive bacteria, comprising 1) an nebulized pharmaceutical formulation comprising: (a) a therapeutically effective amount of bedaquiline; (b) a non-ionic surfactant having a hydrophilic-lipophilic balance value of greater than 10; and (c) an aqueous liquid carrier selected from water, isotonic saline, buffered saline, and aqueous electrolyte solutions; and 2) a nebulizer, wherein the bedaquiline is present in the form of a suspension, and the aerosol particles generated by the system have a mass median aerodynamic diameter of 1 to 5 μm.

[0084] In a further embodiment, a method of treating or preventing a pulmonary infection caused by mycobacteria or other gram-positive bacteria in a patient in need thereof is provided, comprising administering by inhalation a composition according to any of the composition embodiments described above. In a further embodiment, the infection is caused by a mycobacterium species selected from nontuberculosis mycobacteria and the Mycobacterium tuberculosis complex, and combinations thereof. In another embodiment, the nontuberculosis mycobacterium is selected from Mycobacterium avium, Mycobacterium intracellulare, Mycobacterium abscessus, and Mycobacterium leprae, and combinations thereof. In a further embodiment, the infection is an opportunistic infection selected from MAC pulmonary disease and nontuberculous infections in patients with cystic fibrosis, chronic obstructive pulmonary disease, or acquired immune deficiency syndrome. In a further embodiment, the infection is a nontuberculous opportunistic mycobacterial infection in patients with cystic fibrosis. In a further embodiment, the inhalation composition is administered prior to, concurrently with, or subsequent to administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. In a further embodiment, the drug is clofazimine or amikacin. In a further embodiment, the drug is clofazimine.

[0085] In another embodiment of the present invention, there is provided a method for preparing a pharmaceutical composition as described herein, comprising the steps of: (1) homogenizing a suspension of bedaquiline, a non-ionic surfactant, and water to obtain a suspension containing bedaquiline of suitable particle size; (2) adjusting the pH of the suspension resulting from (1) to a pH between pH 5.5 and pH 7.5; (3) adjusting the sodium chloride concentration to a suitable concentration; and (4) adjusting the osmolality to a suitable level. In a further embodiment, the pH is adjusted to 6.5 and the sodium chloride concentration is adjusted to 154 mM sodium chloride. In a further embodiment, the homogenization is performed by high pressure homogenization, wet milling, ultrasonic homogenization, or a combination of such processes. In a further embodiment, the homogenization is performed in multiple homogenization steps. In a further embodiment, the bedaquiline of suitable particle size is a particle having an average size of less than 5 μm and a D90 of less than 6.5 μm. In a further embodiment, suitable particle size bedaquiline is particles having an average size of less than 2 μm and a D90 of less than 3 μm.

[0086] In another embodiment of the present invention, there is provided a method for preparing a pharmaceutical composition as described herein, comprising the steps of: (1) homogenizing a suspension of bedaquiline and a non-aqueous liquid to obtain a suspension containing bedaquiline of suitable particle size; (2) isolating bedaquiline; (3) adding bedaquiline to a non-ionic surfactant and water; (4) adjusting the pH of the suspension resulting from (3) to a pH between pH 5.5 and 7.5; and (5) adjusting the sodium chloride concentration to a suitable concentration. In a further embodiment, the pH is adjusted to 6.5 and the sodium chloride concentration is adjusted to 154 mM sodium chloride. In a further embodiment, the homogenization is performed by high pressure homogenization, wet milling, ultrasonic homogenization, or a combination of such processes. In a further embodiment, the homogenization is performed in multiple homogenization steps. In a further embodiment, the bedaquiline of suitable particle size is a particle having an average size of less than 5 μm and a D90 of less than 6.5 μm. In a further embodiment, suitable particle size bedaquiline is particles having an average size of less than 2 μm and a D90 of less than 3 μm.

[0087] In another embodiment of the present invention, there is provided a method for preparing a pharmaceutical composition as described herein, comprising the steps of: (1) micronizing bedaquiline to obtain bedaquiline of suitable particle size; (2) adding bedaquiline to a non-ionic surfactant and water; (3) adjusting the pH of the suspension resulting from (2) to a pH between pH 5.5 and pH 7.5; and (4) adjusting the sodium chloride concentration to a suitable concentration. In a further embodiment, the pH is adjusted to 6.5 and the sodium chloride concentration is adjusted to 154 mM sodium chloride. In a further embodiment, the micronization of bedaquiline is carried out by jet milling, spray drying, ball milling, or supercritical fluid processing. In a further embodiment, the micronization of bedaquiline is carried out in multiple micronization steps. In a further embodiment, bedaquiline of suitable particle size is particles having an average size of less than 5 μm and a D90 of less than 6.5 μm. In a further embodiment, suitable particle size bedaquiline is particles having an average size of less than 2 μm and a D90 of less than 3 μm.

[0088] In another embodiment of the present invention, there is provided a method for preparing a pharmaceutical composition as described herein, comprising homogenizing a suspension of bedaquiline in water containing a non-ionic surfactant, a suitable concentration of sodium chloride, and adjusted to a pH between pH 5.5 and pH 7.5 to obtain bedaquiline of suitable particle size. In a further embodiment, the pH is adjusted to 6.5 and the sodium chloride concentration is adjusted to 154 mM sodium chloride. In a further embodiment, homogenization is performed by high pressure homogenization, wet milling, ultrasonic homogenization, or a combination of such processes. In a further embodiment, homogenization is performed in multiple homogenization steps. In a further embodiment, bedaquiline of suitable particle size is particles having an average size of less than 5 μm and a D90 of less than 6.5 μm. In a further embodiment, bedaquiline of suitable particle size is particles having an average size of less than 2 μm and a D90 of less than 3 μm.

[0089] In another embodiment of the invention, there is provided a process for preparing the composition of the invention comprising the steps of: (a) homogenizing a suspension of bedaquiline, a non-ionic surfactant and water to obtain a suspension containing bedaquiline of a suitable particle size; (b) adjusting the pH of the resulting suspension to a pH between pH 5.5 and pH 7.5; (c) adjusting the sodium chloride concentration to a suitable concentration; and (d) adjusting the osmolality to a suitable level, wherein steps (b), (c) and (d) may be performed in the following order: (b), (c), (d); (b), (d), (c); (c), (b), (d); (c), (d), (b); (d), (b), (c); or (d), (c), (b).

[0090] In another embodiment of the invention, there is provided a process for preparing a composition of the invention comprising the steps of: (a) homogenizing a suspension of bedaquiline and a non-aqueous liquid to obtain a suspension containing bedaquiline of suitable particle size; (b) isolating bedaquiline; (c) adding bedaquiline to a non-ionic surfactant and water; (d) adjusting the pH of the resulting suspension to a pH between pH 5.5 and pH 7.5; and (e) adjusting the sodium chloride concentration to a suitable concentration, wherein steps (d) and (e) may be performed in the order of (d), (e); or (e), (d).

[0091] In another embodiment of the present invention, there is provided a method for preparing the composition of the present invention, comprising the steps of: (a) micronizing bedaquiline to obtain a suitable particle size of bedaquiline; and (b) adding bedaquiline to water containing a non-ionic surfactant, a suitable concentration of sodium chloride, and adjusted to a pH of between 5.5 and 7.5.

[0092] In another embodiment of the present invention, a pharmaceutical composition for dry powder inhalation is provided, comprising bedaquiline of suitable particle size and a physiologically acceptable pharmacologically inert solid carrier, a solid carrier comprising a physiologically acceptable pharmacologically inert excipient, or a mixture of physiologically acceptable pharmacologically inert excipients of suitable particle size or sizes. In a preferred embodiment of this embodiment, the solid carrier is selected from glucose, arabinose, maltose, saccharose, dextrose and lactose, and combinations thereof. In a further preferred embodiment, the solid carrier is provided in the form of coarse particles having a mass median diameter between 50 μm and 500 μm. In yet another preferred embodiment, bedaquiline is provided in the form of micronized particles having a mass median aerodynamic diameter of less than 5 μm. In yet another preferred embodiment, bedaquiline is provided in the form of micronized particles having a mass median aerodynamic diameter between 1 μm and 3 μm.

[0093] In a further embodiment of the present invention, there is provided a pharmaceutical composition for dry powder inhalation comprising bedaquiline, or a pharma- ceutically acceptable salt or derivative thereof, of suitable particle size, and a physiologically acceptable pharmacologically inert excipient, or a mixture of one or more suitable particle sizes of physiologically acceptable pharmacologically inert excipients, wherein the particles of the composition correspond to a homogenous composition, the homogenous particles comprising both bedaquiline and one or more excipients. In a preferred embodiment of this embodiment, the particles have a mass median aerodynamic diameter of less than 5 μm. In yet another preferred embodiment, the particles have a mass median aerodynamic diameter between 1 μm and 3 μm. In another preferred embodiment of this embodiment, the excipient comprises a phospholipid, or a combination of phospholipids. In yet another preferred embodiment, the excipient comprises a salt. In a further preferred embodiment, the excipient comprises an amino acid or a combination of amino acids. In yet another preferred embodiment, the excipient comprises a sugar or a combination of sugars.

[0094] In another embodiment of the present invention, there is provided a pharmaceutical combination comprising a dry powder inhalation device, a dry powder composition according to any of the embodiments of the dry powder composition described herein before, and a means for introducing the inhalable dry powder composition into the airways of a patient by inhalation. In a preferred embodiment of this embodiment, the dry powder inhalation device is a single dose or multi-dose inhaler. In a further preferred embodiment, the dry powder inhalation device is pre-calibrated or calibrated on the device. In another preferred embodiment, the pharmaceutical combination is intended for use in the treatment and / or prevention of pulmonary infections caused by mycobacteria or other gram-positive bacteria. In another preferred embodiment, the infection is caused by a mycobacterium species selected from nontuberculosis mycobacteria and Mycobacterium tuberculosis complex, and combinations thereof. In another preferred embodiment, the nontuberculous bacteria is selected from Mycobacterium avium, Mycobacterium intracellulare, Mycobacterium abscessus, and Mycobacterium leprae, and combinations thereof. In another preferred embodiment, the infection is an opportunistic infection in a patient with cystic fibrosis, chronic obstructive pulmonary disease, or AIDS, such as Mycobacterium avian complex pulmonary disease or a nontuberculous opportunistic infection associated with cystic fibrosis or chronic obstructive pulmonary disease. In another preferred embodiment, the infection is a nontuberculous opportunistic mycobacterial infection in a patient with cystic fibrosis.

[0095] In another embodiment of the invention, a pharmaceutical composition according to any of the embodiments of the dry powder composition described herein is provided for use in the treatment and / or prevention of pulmonary infections caused by mycobacteria or other gram-positive bacteria. In a preferred embodiment, the pulmonary infection is caused by a mycobacterium species selected from nontuberculosis mycobacteria and Mycobacterium tuberculosis complex, and combinations thereof. In a preferred embodiment, the nontuberculosis mycobacteria is selected from Mycobacterium avium, Mycobacterium intracellulare, Mycobacterium abscessus, and Mycobacterium leprae, and combinations thereof. In another preferred embodiment, the infection is an opportunistic infection in a patient with cystic fibrosis, chronic obstructive pulmonary disease, or AIDS, e.g., Mycobacterium avian complex pulmonary disease or a nontuberculous opportunistic infection associated with cystic fibrosis or chronic obstructive pulmonary disease. In another preferred embodiment, the infection is a nontuberculous opportunistic mycobacterial infection in a patient with cystic fibrosis.

[0096] In another embodiment of the present invention, there is provided a system intended for use in presenting antibiotic activity when treating or providing prophylaxis against pulmonary infections caused by mycobacteria or other gram-positive bacteria, comprising 1) a dry powder pharmaceutical formulation comprising a) a therapeutically effective amount of bedaquiline, b) one or more excipients selected from sugars, amino acids, and phospholipids, and combinations thereof, 2) a container for the formulation selected from a capsule or a blister package, and 3) a dry powder inhaler, wherein bedaquiline is presented in the form of a dry powder and the bedaquiline-containing particles have a mass median diameter of between 1 μm and 5 μm.

[0097] In another embodiment of the invention, there is provided a composition according to any of the embodiments of the dry powder composition described herein, wherein the composition is administered prior to, concurrently with, or after administration of an agent selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxiflxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. In a preferred embodiment of this embodiment, the composition is administered prior to, concurrently with, or after administration of an agent selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, and amikacin, and mixtures thereof. In another preferred embodiment of this embodiment, the composition is administered prior to, concurrently with, or after administration of clofazimine. In another preferred embodiment of this embodiment, the composition is administered prior to, concurrently with, or after administration of amikacin.

[0098] In another embodiment of the present invention, there is provided a combination according to any of the pharmaceutical dry powder combinations described herein, wherein the pharmaceutical combination provided is used for administration before, simultaneously or after administration of a drug selected from clofazimine or a pharmaceutically acceptable salt thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxiflxacin, levofloxacin and para-aminosalicylate, and mixtures thereof. In a preferred embodiment of this embodiment, the combination is used for administration before, simultaneously or after administration of a drug selected from clofazimine, or a pharmaceutically acceptable salt or derivative thereof, and amikacin, and mixtures thereof. In another preferred embodiment of this embodiment, the combination is used for administration before, simultaneously or after administration of a drug selected from clofazimine, or a pharmaceutically acceptable salt or derivative thereof, and amikacin, and mixtures thereof. In another preferred embodiment of this embodiment, the combination is used for administration before, simultaneously or after administration of a drug selected from clofazimine, or a pharmaceutically acceptable salt or derivative thereof, and amikacin, and mixtures thereof. In another preferred embodiment of this embodiment, the combination is used for administration before, simultaneously or after administration of clofazimine. In another preferred embodiment of this embodiment, the combination is used for administration prior to, simultaneously with, or subsequent to administration of amikacin.

[0099] In a further embodiment of the present invention there is provided a method of treating or preventing a pulmonary infection caused by mycobacteria or other gram-positive bacteria in a patient in need thereof comprising administering by inhalation a composition of the present invention as described herein. In a preferred embodiment, the infection is caused by a mycobacterium species selected from nontuberculosis mycobacteria and the Mycobacterium tuberculosis complex, and combinations thereof. In another preferred embodiment, a method of treatment or prevention is provided, wherein the nontuberculosis mycobacterium is selected from Mycobacterium avium, Mycobacterium intracellulare, Mycobacterium abscessus, and Mycobacterium leprae, and combinations thereof. In another preferred embodiment, a method of treatment or prevention is provided, wherein the infection is an opportunistic infection selected from MAC pulmonary disease and nontuberculous infections in patients with cystic fibrosis, chronic obstructive pulmonary disease, or acquired immune deficiency syndrome. In another preferred embodiment, a method of treatment or prevention is provided, wherein the infection is a nontuberculous opportunistic mycobacterial infection in patients with cystic fibrosis.

[0100] In another embodiment of the present invention, there is provided a method of treating or preventing pulmonary infections caused by mycobacteria or other gram-positive bacteria in a patient in need thereof, comprising administering by inhalation a composition according to the present invention as described herein, simultaneously with or after administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. In a preferred embodiment, the drug is clofazimine or amikacin. In another preferred embodiment, the drug is clofazimine.

[0101] Powders suitable for use in dry powder inhalers may consist of micronized agents formed by processes known to the art, such as jet milling, high pressure homogenization, or spray drying. The agent may be delivered alone or may be blended with pharmaceutical grade lactose (e.g., Lactohale®, DFE Pharma, Veghel, Netherlands). The blended formulation may include a tertiary component, such as magnesium stearate, as a release agent (Jetzer et al., “Investigations on the Mechanism of magnesium stearate to modify aerosol performance in dry powder inhaled formulations”, J.Pharm Sci, 107(4)984-998, 2018).

[0102] The spray-dried particles may be 100% drug or may contain one or more additional components to enhance drug stability or powder dispersibility. In one embodiment of the present invention, the additional component is a sugar, such as, but not limited to, trehalose, sucrose, lactose, or fructose. A combination of sugars may also be utilized. In another embodiment, the spray-dried particles of the present invention may include one or more phospholipids. Specific examples of phospholipids include, but are not limited to, phosphatidylcholine, dipalmitoylphosphatidylcholine (DPPC), dipalmitoylphosphatidylethanolamine (DPPE), distearoylphosphatidylcholine (DSPC), dipalmitoylphosphatidylglycerol (DPPG), or any combination thereof. In another embodiment, the particles may contain amino acids. Specific examples of suitable amino acids include, but are not limited to, leucine and isoleucine.

[0103] Optionally, the particles contain one or more sugars, one or more phospholipids, or one or more amino acids, as well as small amounts of strong electrolyte salts, such as, but not limited to, sodium chloride, sodium phosphate, sodium fluoride, sodium sulfate, and calcium carbonate.

[0104] Suitable inhalers are described, for example, in U.S. Patent Nos. 4,069,819; 4,995,385; and 5,997,848. Other examples include, but are not limited to, those known to those skilled in the art as SPINHALER® (Fisons), ROTAHALER® (Glaxo-Wellcome), FLOWCAPS® (Hovione), INHALATOR® (Boehringer Ingelheim), AEROLIZER® (Novartis), and DISKHALER® (Glaxo-Wellcome), Plastiape RS-01®, and others.

[0105] Particle size and distribution The therapeutic efficacy of aerosolized therapy depends on the deposited dose and its distribution. Aerosol particle size is one of the important variables in determining the deposited dose and distribution of drug aerosol in the lungs.

[0106] In general, inhalable aerosol particles undergo deposition by one of two mechanisms: impaction, which usually predominates for larger aerosol particles, and settling, which predominates for smaller aerosol particles. Impaction occurs when the momentum of an inhalable aerosol particle is large enough that the particle does not follow the airflow but encounters a physiological surface. In contrast, settling occurs when very small aerosol particles moving with the inhaled airflow encounter a physiological surface as a result of gravitational settling, primarily in the lower lung.

[0107] Pulmonary drug delivery may be achieved by inhalation of the aerosol through the mouth and pharynx. Aerosol particles with an aerodynamic diameter greater than about 5 μm generally do not reach the lungs; instead, they tend to impact the back of the pharynx and are swallowed and possibly absorbed orally. Aerosol particles with diameters of about 3 μm to about 5 μm are small enough to reach the upper to mid-lung region (down the airways) but are too large to reach the alveoli. Smaller aerosol particles, i.e., about 0.5 to about 3 μm, are capable of reaching the alveolar region. Aerosol particles with diameters smaller than about 0.5 μm tend to be exhaled during ventilatory breathing, but may also be deposited in the alveolar region by breath holding.

[0108] Aerosols used in pulmonary drug delivery are composed of a wide range of aerosol particle sizes, so statistical descriptors are used. Aerosols used in pulmonary drug delivery are typically described by their mass median diameter (MMD), i.e., half of the mass is contained in aerosol particles larger than the MMD, and half of the mass is contained in aerosol particles smaller than the MMD. For particles with uniform density, the volume median diameter (VMD) can be used interchangeably with the MMD. Measurements of VMD and MMD are made by laser diffraction. The width of the distribution is described by the geometric standard deviation (GSD). However, deposition of aerosol particles in the airways is more accurately described by the aerodynamic diameter of the particles, and therefore the mass median aerodynamic diameter is typically used. Measurements of MMAD are made by inertial impaction or time-of-flight measurements. For aqueous particles, the VMD, MMD, and MMAD should be the same. However, if humidity is not controlled as the aerosol passes through the impactor, the MMAD measurement will be smaller than the MMD and VMD due to dehydration. For purposes of this statement, measurements of VMD, MMD and MMAD are considered to be under controlled conditions such that the statements of VMD, MMD and MMAD are comparable.

[0109] Nevertheless, for purposes of description, the aerosol particle size of the aerosol particles will be given as the MMAD as measured by measurements at room temperature using a Next Generation Impactor (NGI) in accordance with the US Pharmacopeial Convention. <601> Aerosols, Nasal Sprays, Metered-Dose Inhalers, and Dry Powder Inhalers, Pharmacopeial Forum (2003), Volume Number 29, pages 1176-1210, is also disclosed in Jolyon Mitchell, Mark Nagel "Particle Size Analysis of Aerosols from Medicinal Inhalers", KONA Powder and Particle Journal (2004), Volume 22, pages 32-65.

[0110] According to the present invention, the aerosol particle size is optimized to maximize deposition of bedaquiline at the site of infection and maximize tolerability. Aerosol particle size may be expressed in terms of mass median aerodynamic diameter (MMAD). Larger particles (e.g., MMAD>5 μm) tend to deposit in the extratracheal and upper airways because they are too large to induce tortuosity in the airways. Non-tolerance (e.g., coughing and bronchospasm) can result from deposition of large particles in the upper airways.

[0111] Therefore, according to a preferred embodiment, the MMAD of the aerosol should be less than about 5 μm, preferably between about 1-5 μm, and more preferably less than 3 μm (<3 μm).

[0112] However, guided breathing can be used to allow larger particles to pass through the extratracheal and upper airways and deeper into the lungs than during ventilated breathing, increasing central and lower lung deposition of the aerosol. Guided breathing can be as slow as 100 mL / min. Thus, the preferred MMAD of the aerosol should be less than about 10 μm when used in guided breathing.

[0113] For suspensions delivered by nebulizers, an equally important factor (in addition to the aerosol particle size) is the particle size and size distribution of the solid particles, in this case bedaquiline. The size of the solid particles in a given aerosol particle must be smaller than the aerosol particle in which it is contained. The larger aerosol particles may contain one or more solid particles. Furthermore, when dealing with dilute suspensions, the majority of the aerosol particles may not contain solid particles. As a result, the drug is preferentially contained in the larger aerosol particles (see, e.g., Finlay, et al., "Predicting regional lung dosages of a nebulized suspension: Pulmicort (budesonide)", Particulate Science and Technology 15:243, 1997).

[0114] For this reason, it is desirable to have solid drug particles significantly smaller than the MMAD of the aerosol particles, for example, if the MMAD of the aerosol particles is 3 μm, the desired solid particles would be 1 μm or smaller.

[0115] An additional consideration is that when using, for example, a vibrating mesh nebulizer, the formulation is pumped through openings in a plate, which breaks the suspension into droplets, so any solid particles must also be smaller than these openings in order to pass through.

[0116] The particle size of the solids in suspension may be given by the average size of the particles and also by the distribution of the particles. The D90 value indicates that 90% of the aerosol mass is contained in particles smaller than D90.

[0117] sprayer For aqueous and other non-compressible liquid systems, a variety of nebulizers (including low volume nebulizers) are available to aerosolize the formulation. Compressor-driven nebulizers incorporate jet technology and use compressed air to generate liquid aerosols. Such devices are commercially available, for example, from Healthdyne Technologies, Inc.; Invacare, Inc.; Mountain Medical Equipment, Inc.; Pari Respiratory, Inc.; Mada Medical, Inc.; Puritan-Bennet; Schuco, Inc., DeVilbiss Health Care, Inc.; and Hospitalak, Inc. Ultrasonic nebulizers rely on mechanical energy in the form of vibrations of piezoelectric crystals to generate respirable droplets, and are commercially available, for example, from Omron Heathcare, Inc. and DeVilbiss Health Care, Inc. Vibrating mesh nebulizers rely on either piezoelectric or mechanical pulses to generate respirable droplets.Other examples of nebulizers contemplated for use with bedaquiline as described herein are disclosed in U.S. Pat. Nos. 4,268,460; 4,046,146; 4,649,911; 4,624,251; 5,164,740; 5,586,550; 5,758,637; 6,644,304; and 6,338. ,443; U.S. Patent No. 5,906,202; U.S. Patent No. 5,934,272; U.S. Patent No. 5,960,792; U.S. Patent No. 5,971,951; U.S. Patent No. 6,070,575; U.S. Patent No. 6,192,876; U.S. Patent No. 6,230,706; U.S. Patent No. 6,349,719; U.S. Patent No. 6,367,470; U.S. Patent No. 6,543,442 No.; U.S. Patent No. 6,584,971; U.S. Patent No. 6,601,581; U.S. Patent No. 4,263,907; U.S. Patent No. 5,709,202; U.S. Patent No. 5,823,179; U.S. Patent No. 6,192,876; U.S. Patent No. 6,644,304; U.S. Patent No. 5,549,102; U.S. Patent No. 6,161,536; U.S. Patent No. 6,557,549 No. 6,612,303; No. 6,962,151; No. 8,596,264, No. 8,720,435, No. 7,131,440, No. 8,739,777, No. 9,975,136; and No. 8,387,895 (all of which are incorporated by reference in their entirety).Commercially available examples of nebulizers in which the bedaquiline compositions described herein can be used include Respirgard II®, Aeroneb®, Aeroneb® Pro, and Aeroneb® Go manufactured by Aerogen; AERx® and AERx Essence™ manufactured by Aradigm; Porta-Neb®, Freeway Freedom™, Sidestream, Ventstream, and I-neb manufactured by Respironics, Inc.; and PARI LCPlus®, PARI LC-Star®, and e-Flow7m manufactured by PARI, GmbH. Further non-limiting examples are disclosed in U.S. Pat. No. 6,196,219.

[0118] According to the present invention, the pharmaceutical composition may be aerosolized using a nebulizer device, preferably selected from an ultrasonic nebulizer, an electrospray nebulizer, a vibrating membrane nebulizer, a jet nebulizer, or a mechanical soft mist inhaler.

[0119] Preferably, the device controls the patient's inhalation flow rate by either an electrical or mechanical process.

[0120] In a further preferred embodiment, aerosol generation by the device is caused by inhalation by the patient, for example the AKITA device.

[0121] Preferred (commercially available) examples of said sprayers / devices to be used according to the present invention include Vectura fox, Pari eFlow, Pari Trek S, Philips Innospire mini, Philips InnoSpire Go, Medspray device, Aeroneb Go, Aerogen Ultra, Respironics Aeroneb, Akita, Medspray Ecomyst and Respimat.

[0122] Therapeutic and / or prophylactic uses The pharmaceutical compositions and pharmaceutical combinations and systems according to the invention are intended for use in the treatment and / or prevention of pulmonary infections caused by mycobacteria or other bedaquiline-susceptible bacteria, such as Staphylococcus aureus (including methicillin-resistant and vancomycin-intermediate resistant strains), Streptococcus pneumoniae, and Enterococcus spp. The pharmaceutical compositions and pharmaceutical formulations of the invention may also be used for the treatment and / or prevention of pulmonary fungal infections.

[0123] Bedaquiline Administration According to the present invention, the pharmaceutical composition is delivered by aerosolization with about 1-5 ml, preferably 1-2 ml, of the pharmaceutical composition of the present invention.

[0124] Thus, the target loaded dose is about 1-5 ml, corresponding to 20-100 mg of bedaquiline, based on a bedaquiline concentration in the pharmaceutical composition of about 20 mg / ml.

[0125] The daily pulmonary dose (i.e., the dose deposited in the lungs) of bedaquiline to be administered according to the present invention, either as a suspension from a nebulizer device or as a dry powder from a dry powder inhaler, is approximately 5-10 mg, which corresponds to a nominal dose (device dose) of 15-30 mg in the case of M. abscessus infection.

[0126] It is understood that one of skill in the art will routinely adjust the pulmonary dose of bedaquiline to be administered (and thus the loaded / nominal dose / volume to be nebulized) based on the MIC of bedaquiline in each bacterial strain, which is well established in the art.

[0127] Depending on the frequency of administration, such as once or twice per day, the daily pulmonary dose will be divided.

[0128] According to the present invention, bedaquiline should be administered once or twice daily, resulting in a total daily pulmonary dose of about 5-10 mg.

[0129] It will be apparent to one skilled in the art that the amounts above relate to the free base of bedaquiline and therefore dosages for derivatives and salts will need to be adjusted based on the MIC of each compound and strain.

[0130] Mucolytic / biofilm modifiers To reduce sputum viscosity during aerosol treatment and to disrupt existing biofilms, treatment and / or prevention according to the present invention may include the additional administration of a mucolytic agent and / or a biofilm disrupting agent.

[0131] These agents may be prepared in a fixed combination or may be administered simultaneously or subsequently to a pharmaceutical composition / aerosol formulation comprising bedaquiline according to the invention.

[0132] The biofilm dispersal / disruption agents, mucolytic and / or mucoactive agents, and / or agents that reduce biofilm formation to be used according to the present invention are selected from nebulized 4-7% hypertonic saline, metaperiodic acid, sodium dodecyl sulfate, sodium bicarbonate, tromethamine, silver nanoparticles, bismuth thiol, ethylenediaminetetraacetic acid, gentamicin-loaded phosphatidylcholine modified gold nanoparticles, chelating agents, cis-2-decenoic acid, D-amino acids, D-enantiomeric peptides, gallium mesoporphyrin IX, gallium protoporphyrin IX, curcumin, patulin, penicillic acid, baicalein, naringenin, ursolic acid, asiatic acid, corosolic acid, fatty acids, host defense peptides, and antimicrobial peptides.

[0133] Additionally, other pharma- ceutically active agents may also be used in combination with the pharmaceutical compositions / aerosol formulations according to the present invention.Such active agents may be selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof.

[0134] These agents may be formulated in a fixed combination or may be administered prior to, simultaneously with or subsequent to a pharmaceutical composition / aerosol formulation comprising bedaquiline according to the invention.

[0135] The following examples serve to more fully describe the manner of using the above-described invention, as well as to set forth the best mode contemplated for carrying out various aspects of the invention, which are within the scope of the claims appended hereto. EXAMPLES

[0136] experiment The following exemplary compositions and formulations have been prepared according to the methods described herein.

[0137] Example 1 Preparation of Suspension Composition 1 A suspension was prepared having the following composition: 500mg of bedaquiline 2.5 ml of Polysorbate 80 (NOF Corporation Hx2) 450mg sodium chloride 47.5ml water

[0138] At this point, the bedaquiline particles had a median size of 14.13 μm with a D90 of 103.48 μm as measured using a Horiba LA950.

[0139] Homogenization was initiated with a Polytron® immersion dispenser PT2500E (Kinematica, Luzern, Switzerland) at 10,000 rpm for 2×5 min. The resulting suspension was then homogenized using a Branson digital sonifier 250D, model 102C, at 70% for 7×3 min on ice.

[0140] The resulting suspension had a pH of 6.91 and an osmality of 341 mOsmol / kg as measured with a semi-micro osmometer K-7400 (Knauer).

[0141] The median size of the bedaquiline particles was measured to be 3.96 μm, with a D10 of 2.29 μm and a D90 of 6.18 μm.

[0142] Determination of minimum inhibitory concentration (MIC) Drug susceptibility testing was performed as recommended by the Clinical and Laboratory Standards Institute by broth microdilution in cation-adjusted Mueller-Hinton broth for Mycobacterium abscessus and by macrodilution using BacTec460 for Mycobacterium avium. MICs were determined by testing susceptibility to concentrations of the composition of Example 1 between 0.05 μg / ml and 8 μg / ml. Results are shown in Table 2. M. avium B16079517 and M. abscessus B15012958 are clinical isolates. M. avium ATCC700898 and M. abscessus CIP104536 are commercial strains. Species MIC μg / ml) M. avium (ATCC700898) 0.03 M. avium (B16079517) 0.03 M. abscessus (CIP104536) 0.125 M. abscessus (B15012958) 0.5

[0143] These results indicate that the composition of Example 1 exhibits significant inhibitory activity against these mycobacteria.

[0144] Preparation of further compositions of bedaquiline A suspension of bedaquiline was prepared having the following composition: 40 mg of bedaquiline 2.0 ml of Polysorbate 80 (NOF Corporation Hx2) 360mg sodium chloride 398ml water

[0145] At this point, the average bedaquiline particle size was 9.30 μm with a D90 of 10.97 μm as measured using a Horiba LA950.

[0146] The suspension was added to a M-110EH-30 Microfluidizer® processor using a H30Z interaction chamber. The suspension was recirculated at 4,400 psi for 5 minutes. At this point, the average bedaquiline particle size was 2.80 μm with a D90 of 4.41 μm.

[0147] A G10Z interaction chamber was set up to recirculate the suspension obtained from the H30Z chamber at 25,000 rpm and samples were collected after 10, 20 and 35 minutes with the following results: (1) after 10 minutes, the mean size of bedaquiline particles was 0.95 μm with a D90 of 2.08 μm; (2) after 20 minutes, the mean size of bedaquiline particles was 0.46 μm with a D90 of 1.16 μm; and (3) after 35 minutes, the mean size of bedaquiline particles was 0.30 μm with a D90 of 0.79 μm. The pH of the 35 minute sample was 6.431 and the osmolality was 297 mOsmol / kg.

[0148] The stability of the above suspension after 35 minutes was measured after standing for 17 days. Measurements performed in triplicate showed that the mean size of bedaquiline particles was 0.37 μm with a D90 of 0.96 μm.

[0149] cell viability The viability of lung epithelial cells was assessed in the presence of bedaquiline suspension using two different cell types: the cell lines A549 (DSMZ; ACC107) and Calu-3 (LGC standard, ATCC-HTB-55).

[0150] A549 cells were cultured in Roswell Park Memorial Institute medium (RPMI1640) + 10% fetal calf serum (FCS), 1% penicillin / streptomycin (10,000 units / ml penicillin; 10,000 units / ml streptomycin) (Pen / Strep), and Calu-3 cells were cultured in Minimum Essential Medium (Gibco by Life Technologies) (MEM) + 10% FCS, 1% non-essential amino acids (supplements for MEM), 1% sodium pyruvate, and 1% Pen / Strep. For routine cell culture, A549 and Calu-3 cells were passaged weekly at 80-90% confluence as follows: cells were cultured in 175 cm 2 The cells were cultured in cell culture flasks of 100 x 100 cm and washed once with 10 ml of transient Dulbecco's Phosphate Buffered Saline (DPBS). After incubation at 37°C with 0.05% trypsin-EDTA for 5 min (A549) or with additional cell scraping for 15 min (Calu-3), the cells were centrifuged at 300 g for 5 min. The cell pellet was resuspended in the respective cell medium. The cells were counted in a Luna cell counter using 10 μl of stained cell suspension (18 μl of cell suspension + 2 μl of acridine orange, Live-Dead stain). For routine culture, 230,000 cells / flask (A549) or 1,300,000 cells / flask (Calu-3), respectively, were transferred to a new T175 cm 2 The cells were seeded in a flask and cultured at 37°C in a 5% CO2 atmosphere.

[0151] MTT is a tetrazolium dye, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide, which is converted to its insoluble formazan by mitochondrial reductase. In living cells, the insoluble formazan can be dissolved by adding the detergent dimethylsulfoxide for 15 minutes. The absorbance of each dye is measured by a plate reader at 590 nm. In calculating the viability after incubation with the test compound, positive and negative controls are included. Hanks' balanced salt solution (HBSS) is used as a negative control and the absorbance value obtained is set to 100% viability. A positive control (1% Triton X100) is used and set to 0% viability. Thus, the IC50 value of the test compound can be determined by measuring the dose-response curve on a logarithmic scale.

[0152] Test samples were prepared for suspensions of bedaquiline and vehicle without bedaquiline as follows.

[0153] Bedaquiline formulations were prepared to contain 1 mg / ml bedaquiline, 0.5% polysorbate 80, 0.9% sodium chloride in distilled water, and vehicle formulations without bedaquiline were prepared to contain 0.5% polysorbate 80 in distilled water or 0.5% polysorbate 80 and 0.9% sodium chloride in water.

[0154] These preparations (designated as 100%) were diluted with HBSS to give the following test formulations:

[0155] Concentration of the vehicle solution Concentration (%) Medium solution (μl) HBSS (μl) 100 2000 0 95 1900 100 90 1800 200 85 1700 300 80 1600 400 70 1400 600 60 1200 800 50 1000 1000 Concentration of bedaquiline-containing suspension Concentration (%) Bedaquiline (μl) Suspension HBSS (μl) Bedaquiline (mg / ml) 100 2000 0 1 90 1800 200 0.9 80 1600 400 0.8 70 1400 600 0.7 60 1200 800 0.6 50 1000 1000 0.5 40 800 1200 0.4 30 600 1400 0.3 20 400 1600 0.2 10 200 1800 0.1 1 20 1980 0.01

[0156] Cells were treated with the test formulations for 4 hours at 37° C. Dose-response curves were set up on a logarithmic scale using cell viability after exposure. A sigmoidal fit allowed the calculation of the IC20, IC50 and IC80 of the test substances. This was carried out in the statistical program Origin® Pro 2019.

[0157] result A549 IC value Bedaquiline suspension Vehicle solution IC20 90~95% 90~95% IC50 85~90% 85~90% IC80 80~85% 85~90% Calu-3 IC value Bedaquiline suspension Vehicle solution IC20 95~100% 95~100% IC50 80~95% 95~100% IC80 60~70% 95~100%

[0158] These data indicate that bedaquiline has minimal cytotoxic effects on cell viability compared to the particular vehicles tested. This specification includes the following disclosure. (Disclosure 1) (a) a therapeutically effective amount of bedaquiline or a pharma- ceutically acceptable derivative or salt thereof; (b) a nonionic surfactant having a hydrophilic-lipophilic equilibrium value greater than 10; and (c) an aqueous liquid carrier selected from water, isotonic saline, buffered saline, and aqueous electrolyte solutions; wherein the bedaquiline or a pharma- ceutically acceptable derivative or salt thereof is provided in the form of particles in a suspension; and The bedaquiline particles, or the particles of the pharma- ceutically acceptable salt of bedaquiline, have a median size of less than 5 μm and a D90 of less than 6.5 μm. Pharmaceutical compositions. (Disclosure 2) 2. The pharmaceutical composition of Disclosure 1, wherein the particles of bedaquiline, or the pharma- ceutically acceptable salt thereof, have a median size of less than 2 μm and a D90 of less than 3 μm. (Disclosure 3) (a) a therapeutically effective amount of bedaquiline; (b) a nonionic surfactant having a hydrophilic-lipophilic equilibrium value greater than 10; and (c) an aqueous liquid carrier selected from water, isotonic saline, buffered saline, and aqueous electrolyte solutions; wherein the bedaquiline is provided in the form of particles in a suspension; and the bedaquiline particles have a median size of less than 5 μm and a D90 of less than 6.5 μm; Pharmaceutical compositions. (Disclosure 4) 4. The pharmaceutical composition of Disclosure 3, wherein the bedaquiline particles have a median size of less than 2 μm and a D90 of less than 3 μm. (Disclosure 5) The nonionic surfactant is selected from the group consisting of polysorbate 20, polysorbate 60, polysorbate 80, stearyl alcohol, polyethylene glycol derivatives of hydrogenated castor oil having a hydrophilic-lipophilic equilibrium value of 14 to 16, polyethylene glycol derivatives of hydrogenated castor oil having a hydrophilic-lipophilic equilibrium value of 15 to 17, sorbitan monolaurate, sorbitan monopalmitate, sorbitan monostearate, polyoxyethylene (20) oleyl ether, polyoxyethylene (20) cetyl ether, polyoxyethylene (10) cetyl ether, polyoxyethylene (10) oleyl ether, polyoxyethylene (100) stearyl ... 5. The pharmaceutical composition according to any one of Disclosures 1 to 4, wherein the glyceryl stearate is selected from the group consisting of caprylocaproyl polyoxyl-8 glyceride, polyethylene glycol (20) monostearate, polyethylene glycol (40) stearate, polyethylene glycol (100) stearate, polyethylene glycol (8) stearate, and polyoxyl 40 stearate, and mixtures thereof. (Disclosure 6) the non-ionic surfactant is polysorbate 80, and The aqueous liquid carrier is distilled water, hypertonic saline or isotonic saline; The pharmaceutical composition according to any one of Disclosures 1 to 5. (Disclosure 7) The pharmaceutical composition according to Disclosure 6, wherein the hypertonic saline is 1% to 7% (w / v) sodium chloride. (Disclosure 8) The pharmaceutical composition according to Disclosure 6, wherein the non-ionic surfactant is ultra-pure polysorbate 80 and the aqueous liquid carrier is isotonic saline. (Disclosure 9) The pharmaceutical composition according to any one of Disclosures 1 to 8, wherein the weight molar osmolality of the composition is within the range of 200 to 700 mOsm / kg. (Disclosure 10) The pharmaceutical composition according to any one of Disclosures 1 to 8, wherein the weight molar osmolality of the composition is within the range of 300 to 400 mOsm / kg. (Disclosure 11) The concentration of the nonionic surfactant is in the range of 0.001% to 5% (v / v) of the total composition; and The amount of bedaquiline is in the range of 0.1% to 20% (w / v) of the total composition. The pharmaceutical composition according to any one of Disclosures 1 to 8. (Disclosure 12) (1) homogenizing a suspension of bedaquiline, the non-ionic surfactant, and water to obtain a suspension containing bedaquiline of suitable particle size; (2) adjusting the pH of the suspension obtained from (1) to a pH between pH 5.5 and pH 7.5; (3) adjusting the sodium chloride concentration to an appropriate concentration; (4) adjusting the osmolality to an appropriate level; 12. The pharmaceutical composition according to any one of Disclosures 1 to 11, prepared by a method comprising: (Disclosure 13) (1) homogenizing a suspension of bedaquiline and a non-aqueous liquid to obtain a suspension containing bedaquiline of an appropriate particle size; (2) isolating the bedaquiline; and (3) adding the bedaquiline to the non-ionic surfactant and water; (4) adjusting the pH of the suspension obtained from (3) to a pH between pH 5.5 and pH 7.5; (5) adjusting the sodium chloride concentration to an appropriate concentration; 12. The pharmaceutical composition according to any one of Disclosures 1 to 11, prepared by a method comprising: (Disclosure 14) (1) micronizing bedaquiline to obtain bedaquiline of a suitable particle size; (2) adding the bedaquiline to the non-ionic surfactant and water; (3) adjusting the pH of the suspension obtained from (2) to a pH between pH 5.5 and pH 7.5; (4) adjusting the sodium chloride concentration to an appropriate concentration; 12. The pharmaceutical composition according to any one of Disclosures 1 to 11, prepared by a method comprising: (Disclosure 15) 12. The pharmaceutical composition according to any one of claims 1 to 11, prepared by a method comprising homogenizing a suspension of bedaquiline in water containing said non-ionic surfactant, a suitable concentration of sodium chloride, and adjusted to a pH between pH 5.5 and pH 7.5 to obtain bedaquiline of a suitable particle size. (Disclosure 16) 14. The pharmaceutical composition prepared by the method of disclosure 12 or 13, wherein the pH is adjusted to 6.5 and the sodium chloride concentration is adjusted to 154 mM sodium chloride. (Disclosure 17) 15. The pharmaceutical composition prepared by the method of disclosure 14, wherein the pH is adjusted to 6.5 and the sodium chloride concentration is adjusted to 154 mM sodium chloride. (Disclosure 18) 16. The pharmaceutical composition prepared by the method of Disclosure 15, wherein the pH is 6.5 and the suitable concentration of sodium chloride is 154 mM sodium chloride. (Disclosure 19) 15. The pharmaceutical composition prepared by the method of disclosure 14, wherein the micronization of bedaquiline is carried out by jet milling, spray drying, ball milling, or supercritical fluid processing. (Disclosure 20) 19. The pharmaceutical composition prepared by the method of any one of Disclosures 12, 13, 15 or 18, wherein the homogenization in step (1) is carried out by high pressure homogenization, high shear homogenization, wet milling, ultrasonic homogenization, or a combination of such processes. (Disclosure 21) 27. A pharmaceutical composition prepared by the method of any one of disclosures 12, 13, 15, 16, 18 or 20, wherein homogenization of bedaquiline is carried out in multiple homogenization steps. (Disclosure 22) 20. A pharmaceutical composition prepared by the method of any one of disclosures 14, 17 or 19, wherein the micronization of bedaquiline is carried out in multiple micronization steps. (Disclosure 23) 23. The pharmaceutical composition prepared by the method according to any one of Disclosures 12 to 22, wherein the bedaquiline of suitable particle size is a particle having an average size of less than 5 μm and a D90 of less than 6.5 μm. (Disclosure 24) 23. The pharmaceutical composition prepared by the method according to any one of Disclosures 12 to 22, wherein the bedaquiline of suitable particle size is particles having an average size of less than 2 μm and a D90 of less than 3 μm. (Disclosure 25) A pharmaceutical combination in the form of an inhalable aerosol prepared by aerosolization of a composition according to any one of claims 1 to 24 by a nebulizer selected from an ultrasonic nebulizer, an electrospray nebulizer, a vibrating membrane nebulizer, a jet nebulizer and a mechanical soft mist inhaler, A pharmaceutical combination wherein the aerosol particles produced by the nebulizer have a mass median aerodynamic diameter of 1 to 5 μm. (Disclosure 26) 26. The pharmaceutical combination according to Disclosure 25, wherein the inhalable aerosol is intended for deposition in the lower lung. (Disclosure 27) 25. The pharmaceutical composition according to any one of Disclosures 1 to 24, to be used in combination with an agent for dispersing and / or disrupting biofilms, a mucolytic and / or mucoactive agent, and / or an agent that reduces biofilm formation selected from nebulized 4-7% hypertonic saline, metaperiodic acid, sodium dodecyl sulfate, sodium bicarbonate, tromethamine, silver nanoparticles, bismuth thiol, ethylenediaminetetraacetic acid, gentamicin-loaded phosphatidylcholine modified gold nanoparticles, a chelating agent, cis-2-decenoic acid, D-amino acids, D-enantiomeric peptides, gallium mesoporphyrin IX, gallium protoporphyrin IX, curcumin, patulin, penicillic acid, baicalein, naringenin, ursolic acid, asiatic acid, corosolic acid, fatty acids, host defense peptides, and antimicrobial peptides. (Disclosure 28) 27. The pharmaceutical combination according to Disclosure 25 or 26, to be used in combination with an agent for dispersing and / or disrupting biofilm, a mucolytic and / or mucoactive agent, and / or an agent that reduces biofilm formation selected from nebulized 4-7% hypertonic saline, metaperiodic acid, sodium dodecyl sulfate, sodium bicarbonate, tromethamine, silver nanoparticles, bismuth thiol, ethylenediaminetetraacetic acid, gentamicin-loaded phosphatidylcholine modified gold nanoparticles, a chelating agent, cis-2-decenoic acid, D-amino acids, D-enantiomeric peptides, gallium mesoporphyrin IX, gallium protoporphyrin IX, curcumin, patulin, penicillic acid, baicalein, naringenin, ursolic acid, asiatic acid, corosolic acid, fatty acids, host defense peptides, and antimicrobial peptides. (Disclosure 29) 25. A pharmaceutical composition according to any one of claims 1 to 24, intended for use in the treatment and / or prevention of pulmonary infections caused by mycobacteria or other gram-positive bacteria. (Disclosure 30) 27. The pharmaceutical combination according to disclosure 25 or 26, intended for use in the treatment and / or prevention of pulmonary infections caused by mycobacteria or other gram-positive bacteria. (Disclosure 31) The infection is caused by nontuberculous mycobacteria. mycobacteria and Mycobacterium 30. The pharmaceutical composition contemplated for use as described in Disclosure 29, which is caused by a Mycobacterium species selected from Mycobacterium tuberculosis complex, ... (Disclosure 32) The infection is caused by nontuberculous mycobacteria. mycobacteria and Mycobacterium The pharmaceutical combination contemplated for use as described in Disclosure 30 is caused by a Mycobacterium species selected from Mycobacterium tuberculosis complex, Mycobacterium tuberculosis complex, and combinations thereof. (Disclosure 33) The nontuberculous mycobacteria mycobacteria, Mycobacterium avium avium, Mycobacterium intracellulare intracellulare, Mycobacterium abscessus abscessus, and Mycobacterium leprae), and combinations thereof. (Disclosure 34) The nontuberculous mycobacteria mycobacteria, Mycobacterium avium avium, Mycobacterium intracellulare intracellulare, Mycobacterium abscessus abscessus, and Mycobacterium leprae), and combinations thereof. (Disclosure 35) 32. The pharmaceutical composition contemplated for use according to disclosure 31, wherein the infection is an opportunistic infection selected from MAC pulmonary disease and non-tuberculous infections in patients with cystic fibrosis, chronic obstructive pulmonary disease or acquired immune deficiency syndrome. (Disclosure 36) 33. The pharmaceutical combination contemplated for use according to disclosure 32, wherein said infection is an opportunistic infection selected from MAC pulmonary disease and non-tuberculous infections in patients with cystic fibrosis, chronic obstructive pulmonary disease or acquired immune deficiency syndrome. (Disclosure 37) 36. The pharmaceutical composition contemplated for use according to disclosure 35, wherein said infection is a non-tuberculous opportunistic mycobacterial infection in a patient with cystic fibrosis. (Disclosure 38) 37. A pharmaceutical combination as contemplated for use according to disclosure 36, wherein said infection is a non-tuberculous opportunistic mycobacterial infection in a patient with cystic fibrosis. (Disclosure 39) 1. A system intended for use in providing antibiotic activity when treating or providing prophylaxis against pulmonary infections caused by mycobacteria or other gram-positive bacteria, comprising: 1)(a) a therapeutically effective amount of bedaquiline; (b) a nonionic surfactant having a hydrophilic-lipophilic equilibrium value greater than 10; and (c) an aqueous liquid carrier selected from water, isotonic saline, buffered saline, and aqueous electrolyte solutions; 1. A spray pharmaceutical formulation comprising and 2) Sprayer Including, wherein said bedaquiline is present in the form of a suspension; and The aerosol particles produced by the system have a mass median aerodynamic diameter of 1 to 5 μm. system. (Disclosure 40) 29. The pharmaceutical combination according to any one of Disclosures 25, 26 or 28, wherein the spray device exhibits an output rate of 0.1-1.0 ml / min. (Disclosure 41) 40. The pharmaceutical combination contemplated for use according to any one of disclosures 30, 32, 34, 36 or 38, wherein said spray device exhibits an output rate of 0.1 to 1.0 ml / min. (Disclosure 42) 41. The pharmaceutical combination according to any one of Disclosures 25, 26, 28 or 40, wherein the total inhalation volume is between 1 ml and 5 ml. (Disclosure 43) A pharmaceutical combination contemplated for use according to any one of disclosures 30, 32, 34, 36, 38 or 41, wherein said total inhalation volume is between 1 ml and 5 ml. (Disclosure 44) 28. A pharmaceutical composition contemplated for use as described in Disclosure 27, administered prior to, concurrently with or following administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. (Disclosure 45) 38. A pharmaceutical composition contemplated for use as described in any one of disclosures 29, 31, 33, 35, or 37, administered prior to, concurrently with, or following administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. (Disclosure 46) 29. A pharmaceutical combination contemplated for use as described in Disclosure 28, for administration prior to, concurrently with or subsequent to administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. (Disclosure 47) A pharmaceutical combination contemplated for use according to any one of disclosures 30, 32, 34, 36, 38, 40 or 43, for administration prior to, concurrently with or subsequent to administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. (Disclosure 48) 45. A pharmaceutical composition as contemplated for use according to Disclosure 44, wherein said drug is clofazimine. (Disclosure 49) A pharmaceutical composition as contemplated for use according to Disclosure 45, wherein said drug is clofazimine. (Disclosure 50) A pharmaceutical combination contemplated for use according to disclosure 46, wherein said drug is clofazimine. (Disclosure 51) A pharmaceutical combination contemplated for use according to disclosure 47, wherein said drug is clofazimine. (Disclosure 52) 45. The pharmaceutical composition contemplated for use according to Disclosure 44, wherein said drug is amikacin. (Disclosure 53) A pharmaceutical composition as contemplated for use according to Disclosure 45, wherein the drug is amikacin. (Disclosure 54) A pharmaceutical combination contemplated for use according to disclosure 46, wherein said drug is amikacin. (Disclosure 55) A pharmaceutical combination contemplated for use according to disclosure 47, wherein said drug is amikacin. (Disclosure 56) 26. A method for treating or preventing a pulmonary infection caused by mycobacteria or other gram-positive bacteria in a patient in need thereof, comprising administering by inhalation a composition described in any one of Disclosures 1-24. (Disclosure 57) The infection is caused by nontuberculous mycobacteria. mycobacteria and Mycobacterium 57. The method of claim 56, wherein the Mycobacterium species is selected from the group consisting of Mycobacterium tuberculosis complex, Mycobacterium tuberculosis complex, and combinations thereof. (Disclosure 58) The nontuberculous mycobacterium mycobacterium avium avium, Mycobacterium intracellulare intracellulare, Mycobacterium abscessus abscessus, and Mycobacterium leprae), and combinations thereof. (Disclosure 59) 57. The method of treatment or prevention according to Disclosure 56, wherein the infection is an opportunistic infection selected from MAC pulmonary disease and non-tuberculous infections in patients with cystic fibrosis, chronic obstructive pulmonary disease or acquired immune deficiency syndrome. (Disclosure 60) 60. The method of treatment or prevention according to Disclosure 59, wherein the infection is a nontuberculous opportunistic mycobacterial infection in a patient with cystic fibrosis. (Disclosure 61) A method for treating or preventing pulmonary infections caused by mycobacteria or other gram-positive bacteria in a patient in need thereof, comprising administering by inhalation a composition according to any one of Disclosures 1-24 prior to, concurrently with, or following administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. (Disclosure 62) 62. The method of treatment or prevention described in Disclosure 61, wherein the drug is clofazimine or amikacin. (Disclosure 63) 63. The method of treatment or prevention described in Disclosure 62, wherein the drug is clofazimine. (Disclosure 64) (1) homogenizing a suspension of bedaquiline, the non-ionic surfactant, and water to obtain a suspension containing bedaquiline of suitable particle size; (2) adjusting the pH of the suspension obtained from (1) to a pH between pH 5.5 and pH 7.5; (3) adjusting the sodium chloride concentration to an appropriate concentration; (4) adjusting the osmolality to an appropriate level; A method for preparing the pharmaceutical composition according to any one of Disclosures 1 to 11, comprising: (Disclosure 65) (1) homogenizing a suspension of bedaquiline and a non-aqueous liquid to obtain a suspension containing bedaquiline of the appropriate particle size; (2) isolating the bedaquiline; and (3) adding the bedaquiline to the non-ionic surfactant and water; (4) adjusting the pH of the suspension obtained from (3) to a pH between 5.5 and 7.5; (5) adjusting the sodium chloride concentration to an appropriate concentration; A method for preparing the pharmaceutical composition according to any one of Disclosures 1 to 11, comprising: (Disclosure 66) (1) micronizing bedaquiline to obtain bedaquiline of a suitable particle size; (2) adding the bedaquiline to the non-ionic surfactant and water; (3) adjusting the pH of the suspension obtained from (2) to a pH between pH 5.5 and pH 7.5; (4) adjusting the sodium chloride concentration to an appropriate concentration; A method for preparing the pharmaceutical composition according to any one of Disclosures 1 to 11, comprising: (Disclosure 67) A method for preparing a pharmaceutical composition according to any one of claims 1 to 11, comprising homogenizing a suspension of bedaquiline in water containing said non-ionic surfactant, a suitable concentration of sodium chloride, and adjusted to a pH between pH 5.5 and pH 7.5 to obtain bedaquiline of a suitable particle size. (Disclosure 68) 68. The method of any one of Disclosures 64, 65, or 67, wherein the pH is adjusted to 6.5 and the sodium chloride concentration is adjusted to 154 mM sodium chloride. (Disclosure 69) 67. The method of claim 66, wherein the pH is 6.5 and the suitable concentration of sodium chloride is 154 mM sodium chloride. (Disclosure 70) 67. The method of claim 66, wherein the micronization of the bedaquiline is carried out by jet milling, spray drying, ball milling, or supercritical fluid processing. (Disclosure 71) 69. The method of any one of Disclosures 64, 65, 67 or 68, wherein said homogenization is carried out by high pressure homogenization, wet milling, ultrasonic homogenization, or a combination of such processes. (Disclosure 72) The method of any one of Disclosures 64, 65, 67, 68 or 71, wherein said homogenization of bedaquiline is carried out in multiple homogenization steps. (Disclosure 73) The method of any one of Disclosures 66, 69 or 70, wherein said micronization of bedaquiline is carried out in multiple micronization steps. (Disclosure 74) The method according to any one of Disclosures 64 to 73, wherein the bedaquiline of suitable particle size is a particle having an average size of less than 5 μm and a D90 of less than 6.5 μm. (Disclosure 75) The bedaquiline of suitable particle size is a particle having an average size of less than 2 μm and a D90 of less than 3 μm. (Disclosure 76) 12. A method for preparing a pharmaceutical composition according to any one of Disclosures 1 to 11, comprising: (a) homogenizing a suspension of bedaquiline, the non-ionic surfactant and water to obtain a suspension containing bedaquiline of suitable particle size; (b) adjusting the pH of the resulting suspension to a pH between pH 5.5 and pH 7.5; (c) adjusting the sodium chloride concentration to an appropriate concentration; and (d) adjusting the osmolality to an appropriate level, wherein steps (b), (c) and (d) may be performed in the following order: (b), (c), (d); (b), (d), (c); (c), (b), (d); (c), (d), (b); (d), (b), (c); or (d), (c), (b). (Disclosure 77) 12. A method for preparing a pharmaceutical composition according to any one of Disclosures 1 to 11, comprising: (a) homogenizing a suspension of bedaquiline and a non-aqueous liquid to obtain a suspension containing bedaquiline of the appropriate particle size; (b) isolating the bedaquiline; (c) adding the bedaquiline to the non-ionic surfactant and water; (d) adjusting the pH of the resulting suspension to a pH between pH 5.5 and pH 7.5; and (e) adjusting the sodium chloride concentration to an appropriate concentration, wherein steps (d) and (e) may be performed in the order of (d), (e); or (e), (d). (Disclosure 78) A method for preparing a pharmaceutical composition according to any one of Disclosures 1 to 11, comprising: (a) micronizing bedaquiline to obtain bedaquiline of an appropriate particle size; and (b) adding the bedaquiline to water containing the non-ionic surfactant, an appropriate concentration of sodium chloride, and adjusted to a pH between pH 5.5 and pH 7.5. (Disclosure 79) A pharmaceutical composition for dry powder inhalation comprising bedaquiline, or a pharma- ceutical acceptable salt or derivative thereof, of a suitable particle size, and a physiologically acceptable, pharmacologically inert excipient, or a mixture of one or more physiologically acceptable, pharmacologically inert excipients of a suitable particle size. (Disclosure 80) A pharmaceutical composition for dry powder inhalation comprising bedaquiline of a suitable particle size and a physiologically acceptable, pharmacologically inert solid carrier, a solid carrier comprising a physiologically acceptable, pharmacologically inert excipient, or a mixture of one or more suitable particle sizes of physiologically acceptable, pharmacologically inert excipients. (Disclosure 81) 81. The composition of claim 79 or 80, wherein the solid carrier is selected from glucose, arabinose, maltose, sucrose, dextrose and lactose, and combinations thereof. (Disclosure 82) The composition according to any one of Disclosures 79 to 81, wherein the solid carrier is provided in the form of coarse particles having a mass median diameter between 50 and 500 μm. (Disclosure 83) The composition of any one of Disclosures 79-82, wherein the bedaquiline is provided in the form of micronized particles having a mass median aerodynamic diameter of less than 5 μm. (Disclosure 84) The composition of Disclosure 83, wherein the bedaquiline is provided in the form of micronized particles having a mass median aerodynamic diameter of between 1 μm and 3 μm. (Disclosure 85) The composition of Disclosure 79, wherein the particles correspond to a homogenous composition and the particles comprise both bedaquiline and the one or more excipients. (Disclosure 86) 86. The composition of Disclosure 85, wherein the particles have a mass median aerodynamic diameter of less than 5 μm. (Disclosure 87) The composition of any one of Disclosures 85 and 86, wherein the particles have a mass median aerodynamic diameter between 1 μm and 3 μm. (Disclosure 88) 88. The composition of any one of Disclosures 85-87, wherein the excipient comprises a phospholipid or a combination of phospholipids. (Disclosure 89) The composition of any one of Disclosures 85-87, wherein the excipient comprises a salt. (Disclosure 90) 88. The composition of any one of Disclosures 85-87, wherein the excipient comprises an amino acid or a combination of amino acids. (Disclosure 91) 88. The composition of any one of Disclosures 85-87, wherein the excipient comprises a sugar or a combination of sugars. (Disclosure 92) A pharmaceutical combination comprising a dry powder inhaler, the dry powder composition according to any one of Disclosures 79 to 91, and a means for introducing said inhalable dry powder composition into the respiratory tract of a patient by inhalation. (Disclosure 93) 93. The pharmaceutical combination of Disclosure 92, wherein the dry powder inhalation device is a single dose or a multi-dose inhaler. (Disclosure 94) The pharmaceutical combination of Disclosure 92, wherein the dry powder inhalation device is precalibrated or calibrated on the device. (Disclosure 95) A pharmaceutical composition according to any one of disclosures 79 to 91, intended for use in the treatment and / or prevention of pulmonary infections caused by mycobacteria or other gram-positive bacteria. (Disclosure 96) 95. The pharmaceutical combination according to any one of disclosures 92 to 94, intended for use in the treatment and / or prevention of pulmonary infections caused by mycobacteria or other gram-positive bacteria. (Disclosure 97) The infection is caused by nontuberculous mycobacteria. mycobacteria and Mycobacterium The pharmaceutical composition of Disclosure 95, wherein the Mycobacterium species is selected from the group consisting of Mycobacterium tuberculosis complex, Mycobacterium tuberculosis complex, and combinations thereof. (Disclosure 98) The infection is caused by nontuberculous mycobacteria. mycobacteria and Mycobacterium The pharmaceutical combination contemplated for use as described in Disclosure 96 is caused by a Mycobacterium species selected from Mycobacterium tuberculosis complex, Mycobacterium tuberculosis complex, and combinations thereof. (Disclosure 99) The nontuberculous mycobacteria mycobacteria, Mycobacterium avium avium, Mycobacterium intracellulare intracellulare, Mycobacterium abscessus abscessus, and Mycobacterium leprae), and combinations thereof. (Disclosure 100) The nontuberculous mycobacteria mycobacteria, Mycobacterium avium avium, Mycobacterium intracellulare intracellulare, Mycobacterium abscessus abscessus, and Mycobacterium leprae), and combinations thereof. (Disclosure 101) The pharmaceutical composition contemplated for use according to Disclosure 97, wherein the infection is an opportunistic infection selected from MAC pulmonary disease and non-tuberculous infections in patients with cystic fibrosis, chronic obstructive pulmonary disease or acquired immune deficiency syndrome. (Disclosure 102) A pharmaceutical combination contemplated for use according to disclosure 98, wherein the infection is an opportunistic infection selected from MAC pulmonary disease and non-tuberculous infections in patients with cystic fibrosis, chronic obstructive pulmonary disease or acquired immune deficiency syndrome. (Disclosure 103) The pharmaceutical composition contemplated for use according to disclosure 101, wherein said infection is a non-tuberculous opportunistic mycobacterial infection in a patient with cystic fibrosis. (Disclosure 104) The pharmaceutical combination according to disclosure 102, wherein said infection is a nontuberculous opportunistic mycobacterial infection in a patient with cystic fibrosis. (Disclosure 105) 1. A system intended for use in providing antibiotic activity when treating or providing prophylaxis against pulmonary infections caused by mycobacteria or other gram-positive bacteria, comprising: 1)(a) a therapeutically effective amount of bedaquiline; (b) one or more excipients selected from sugars, amino acids, and phospholipids, and combinations thereof; 1. A dry powder pharmaceutical formulation comprising: 2) a container for the formulation selected from a capsule or a blister package; and 3) Dry powder inhaler wherein the bedaquiline is present in the form of a dry powder and the bedaquiline-containing particles have a mass median diameter of 1 μm to 5 μm. (Disclosure 106) The pharmaceutical composition of any one of Disclosures 95, 97, 99, 101 or 103, administered prior to, concurrently with or subsequent to said administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. (Disclosure 107) The pharmaceutical combination of any one of Disclosures 96, 98, 100, 102 or 104, for use in administering prior to, simultaneously with or following administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. (Disclosure 108) The pharmaceutical composition of Disclosure 106, wherein the drug is clofazimine. (Disclosure 109) The pharmaceutical combination according to Disclosure 107, wherein the drug is clofazimine. (Disclosure 110) The pharmaceutical composition of Disclosure 106, wherein the drug is clofazimine. (Disclosure 111) The pharmaceutical composition of Disclosure 106, wherein the drug is amikacin. (Disclosure 112) The pharmaceutical combination of Disclosure 107, wherein the drug is amikacin. (Disclosure 113) A method for treating or preventing a pulmonary infection caused by mycobacteria or other gram-positive bacteria in a patient in need thereof, comprising administering by inhalation a composition described in any one of Disclosures 79-91. (Disclosure 114) The infection is caused by nontuberculous mycobacteria. mycobacteria and Mycobacterium The method of claim 113, wherein the Mycobacterium species is selected from the group consisting of Mycobacterium tuberculosis complex, Mycobacterium tuberculosis complex, and combinations thereof. (Disclosure 115) The nontuberculous mycobacterium mycobacterium avium avium, Mycobacterium intracellulare intracellulare, Mycobacterium abscessus abscessus, and Mycobacterium leprae), and combinations thereof. (Disclosure 116) The method of treatment or prevention according to Disclosure 113, wherein the infection is an opportunistic infection selected from MAC pulmonary disease and non-tuberculous infections in patients with cystic fibrosis, chronic obstructive pulmonary disease or acquired immune deficiency syndrome. (Disclosure 117) The method of treatment or prevention according to Disclosure 116, wherein the infection is a nontuberculous opportunistic mycobacterial infection in a patient with cystic fibrosis. (Disclosure 118) A method for treating or preventing pulmonary infections caused by mycobacteria or other gram-positive bacteria in a patient in need thereof, comprising administering by inhalation a composition described in any one of Disclosures 79-91 prior to, concurrently with, or following administration of a drug selected from clofazimine or a pharma- ceutically acceptable salt or derivative thereof, cefoxitin, amikacin, clarithromycin, pyrazinamide, rifampin, moxifloxacin, levofloxacin, and para-aminosalicylate, and mixtures thereof. (Disclosure 119) The method of treatment or prevention described in Disclosure 118, wherein the drug is clofazimine or amikacin. (Disclosure 120) The method of treatment or prevention described in Disclosure 119, wherein the drug is clofazimine.

Claims

1. (a) a therapeutically effective amount of bedaquiline or a pharma- ceutically acceptable salt thereof; (b) a nonionic surfactant having a hydrophilic-lipophilic balance value of greater than 10; and (c) an aqueous liquid carrier selected from water, isotonic saline, buffered saline, and aqueous electrolyte solutions; wherein the bedaquiline or pharma- ceutically acceptable salt thereof is provided in the form of particles in a suspension; and The bedaquiline particles, or the particles of the pharma- ceutically acceptable salt of bedaquiline, have a median size of less than 5 μm and a D90 of less than 6.5 μm. A pharmaceutical composition for administration by inhalation, except when it contains chitosan particles.

2. 2. The pharmaceutical composition of claim 1, wherein the particles of bedaquiline, or the pharma- ceutically acceptable salt thereof, have a median size of less than 2 μm and a D90 of less than 3 μm.

3. The nonionic surfactant is selected from the group consisting of polysorbate 20, polysorbate 60, polysorbate 80, stearyl alcohol, polyethylene glycol derivatives of hydrogenated castor oil having a hydrophilic-lipophilic balance value of 14 to 16, polyethylene glycol derivatives of hydrogenated castor oil having a hydrophilic-lipophilic balance value of 15 to 17, sorbitan monolaurate, sorbitan monopalmitate, sorbitan monostearate, polyoxyethylene (20) oleyl ether, polyoxyethylene (20) cetyl ether, polyoxyethylene (10) cetyl ether, polyoxyethylene (10) oleyl ether, polyoxyethylene (10) 2. The pharmaceutical composition of claim 1, wherein the polyoxyethylene (10) stearyl ether, polyoxyethylene (20) stearyl ether, polyoxyethylene (4) lauryl ether, polyoxyethylene (20) cetyl ether, polyoxyethylene (2) cetyl ether, caprylocaproyl polyoxyl-8 glyceride, polyethylene glycol (20) monostearate, polyethylene glycol (40) stearate, polyethylene glycol (100) stearate, polyethylene glycol (8) stearate, and polyoxyl 40 stearate, and mixtures thereof.

4. the non-ionic surfactant is polysorbate 80, and The aqueous liquid carrier is distilled water, hypertonic saline or isotonic saline; The pharmaceutical composition of claim 1.

5. 5. The pharmaceutical composition of claim 4, wherein the hypertonic saline is 1% to 7% (w / v) sodium chloride.

6. 5. The pharmaceutical composition of claim 4, wherein the non-ionic surfactant is ultra-pure polysorbate 80 and the aqueous liquid carrier is isotonic saline.

7. 2. The pharmaceutical composition of claim 1, wherein the composition has an osmolality in the range of 200 to 700 mOsm / kg.

8. The concentration of the non-ionic surfactant is in the range of 0.001% to 5% (v / v) of the total composition; and the amount of bedaquiline is in the range of 0.1% to 20% (w / v) of the total composition; The pharmaceutical composition of claim 1.

9. (1) homogenizing a suspension of bedaquiline, the non-ionic surfactant, and water to obtain a suspension containing bedaquiline of suitable particle size; (2) adjusting the pH of the suspension obtained from (1) to a pH between pH 5.5 and pH 7.5; (3) adjusting the sodium chloride concentration to an appropriate concentration; (4) adjusting the osmolality to an appropriate level; and 2. A method for preparing the pharmaceutical composition of claim 1, comprising:

10. 10. The method of claim 9, wherein the pH is adjusted to 6.5 and the sodium chloride concentration is adjusted to 154 mM sodium chloride.

11. 10. The method of claim 9, wherein the homogenization in step (1) is carried out by high pressure homogenization, high shear homogenization, wet milling, ultrasonic homogenization, or a combination of such processes.

12. 10. The method of claim 9, wherein the homogenization of bedaquiline is carried out in multiple homogenization steps.

13. 10. The method of claim 9, wherein the suitable particle size of bedaquiline is a particle having an average size of less than 5 μm and a D90 of less than 6.5 μm.

14. 10. The method of claim 9, wherein the suitable particle size of bedaquiline is a particle having an average size of less than 2 μm and a D90 of less than 3 μm.

15. 13. A method for preparing a pharmaceutical combination in the form of an inhalable aerosol comprising aerosolizing the composition of claim 1 by a nebulizer selected from an ultrasonic nebulizer, an electrospray nebulizer, a vibrating membrane nebulizer, a jet nebulizer, and a mechanical soft mist inhaler, wherein the aerosol particles produced by the nebulizer have a mass median aerodynamic diameter of 1-5 μm.

16. 1. A system intended for use in providing antibiotic activity when treating or providing prophylaxis against pulmonary infections caused by mycobacteria or other gram-positive bacteria, comprising: 1) (a) a therapeutically effective amount of bedaquiline; (b) a nonionic surfactant having a hydrophilic-lipophilic balance value of greater than 10; and (c) an aqueous liquid carrier selected from water, isotonic saline, buffered saline, and aqueous electrolyte solutions; 1. A spray pharmaceutical formulation comprising and 2) Sprayer Including, wherein said bedaquiline is present in the form of a suspension; and the aerosol particles produced by the system have a mass median aerodynamic diameter of 1 to 5 μm; system (except when said spray pharmaceutical formulation comprises chitosan particles).

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