Int J App Pharm, Vol 10, Issue 3, 2018, 13-18Review Article



1Department of Pharmacy Practice, 2Department of Pharmaceutics, 3Department of Pharmacology, J. K. K. Nattraja College of Pharmacy, Kumarapalayam 638183

Received: 19 Sep 2017, Revised and Accepted: 13 Apr 2018


The world is running out of antibiotics. Between 1940 and 1962, more than 20 new classes of antibiotics were marketed. Since then, only two new classes of antibiotics were marketed. Now, not enough analogues are reaching the market to stem the tide of antibiotic resistance, particularly among gram-negative bacteria which indicates the need of novel antibiotics for their effective action. This review describes those antibiotics in late-stage clinical development. Most of them belong to existing antibiotic classes and a few with a narrow spectrum of activity are novel compounds directed against novel targets. The reasons for some of the past failures to find new molecules and a path forward to help attract investments to fund the discovery of new antibiotics are described.

Keywords: Antibiotics, Clinical development, Narrow spectrum


The antibiotics are the cornerstones of recent medicine after the entry of penicillin, which came into widespread use in the beginning of the 1940s. [1] By 1950s, multiple numbers of newer classes of antibiotics came into the scene, over the next twenty years. [2] Nowadays it is difficult to treat and do certain medical procedures which are extensively used, like chemotherapy, organ transplants, joint operations or the provision of care for premature babies without the antibiotics [1]. Moreover, they can control both morbidity and mortality rate in humans and animals. [3] To brief outing, they have become the lifesaving treatment for all types of infections in humans as well as animals. The timeline of new class antibiotics has been given in table 1.

Table 1: Time line of antibiotics

Year introduced Class of drug





























Now, however, two developments are resulting in more and more difficult to treat the bacterial infections with the antibiotics successfully, including the increasing number of antibiotic-resistant pathogens and the second one is that the number of new antibiotics developed since the 1970s has decreased [4]. It was estimated that infections that can be treated completely are also becoming more complicated to treat, increasing costs of healthcare facilities, and patient mortality is increasing with costs to the society. The antibiotic effectiveness has to decrease now and many of the microorganisms are resistant to multiple antibiotics [5]. The issue of antibiotic resistance, though not new, has amplified in the previous 10 to 15 y and creates a serious threat to the treatment of infections. Certain new investigational studies were reported that, among all the multidrug-resistant pathogens like S. aureus and P. aeruginosa, Acinetobacter species are the major infective organism which can cause even life-threatening resistant infections. The improper intake of antibiotic dosage or lack of sensitive antibiotic agents to fight against these types of organisms may be the reason for the occurrence of such infections [6].

Despite this increase in the multidrug-resistant pathogens, the development of antibacterial agents is declining, [7] that is, there are not enough antibiotics for treating such infections [4]. This antibiotic deficit will become more and more problematic in the years to come.

As per World Health Organization (WHO), the antibiotic resistance is one among the serious hazard to human health and the consequences of antibiotic-resistant bacterial infections are greater than ever [4]. So, new antibiotics are critically needed to alleviate the problems associated with this antibiotic resistance [8, 9]. The Infectious Diseases Society of America (IDSA, 2010) estimated that at least another 10 antibiotics, which are active against these superbugs, are required to enter the market within ensuing ten years [10]. It ought to be noted that antibiotics, which were already in market use are complex natural products with multiple binding sites on the target, making it less likely for resistance selection. Moreover, the prevalence of treatment difficulty for both resistant and multi-resistant nosocomial organisms are greatly rising, both for Gram-negative and Gram-positive bacteria among this; gram-negative organisms are producing a greater threat [11].

Thus, the demand for new antibiotics is critical for some gram-negative microbes as compared to gram-positive microbes since the new molecules or compounds will produce action in new pathways to eradicate such microbes [12]. Generally, small proteins are the greatest source of new antibiotics called antimicrobial peptides (AMPs) and many of these AMPs are derived from natural molecules [13]. The current study reviews all the current articles on clinically developing antibiotics and describes their needs and scope in the market.

Search criteria

Articles related to new antibiotics and their developments were reviewed for the study, most of them were from Pubmed databases. Articles between the years of 2000 and 2017 were selected for reviewing and the points were extracted. Primary resources were given the first preference for reviewing.

Approval and development of antibiotics from the ‘Golden Era’

The response to the entry of any new antibiotic has lead to the development of resistant bacterial variants so, new antibiotic compounds should be needed constantly to alleviate the associated problems. During the "golden era" of antibiotic evolution, that is, in the years of 1940s to 1970s, new antibiotics with new actions were incessantly developed, which made it possible to manage the threat of gradually rising resistant strains. [8] The European Medicines Agency (EMA) and the American Food and Drug Administration (FDA) were the two agencies responsible for making the approval decisions for new antibiotics. The new antibiotics, which are approved in the year of 2000 and 2011, are listed below (table 2).

Table 2: Status of antibiotics approved by the FDA and the EMA between 2000 and 2011

Substance Class Rejected by FDA Approved by FDA Approved by EMA
Linezolid Oxazolidinones 2000
Ertapenem Carbapenems 2001 2002
Cefditoren Cephalosporines 2001
Gemifloxacin Fluoroquinolones 2003
Daptomycin Lipopeptides 2003 2006
Telithromycin Macrolides 2004
Tigecycline Glycylcyclines 2005 2006
Faropenem Penems 2006
Retapamulin Pleuromutilins 2007 2008
Dalbavancin Glycopeptides 2007
Doripenem Carbapenems 2007 2008
Oritavancin Glycopeptides 2008
Cethromycin Macrolides 2009
Cethromycin Macrolides 2009
Iclaprim Trimethoprims 2009
Besifloxacin Fluoroquinolones 2009
Telavancin Glycopeptides 2009 2011
Ceftobiprole Cephalosporines 2009
Fidaxomicin Lipiarmycins 2011 2011
Colistimethate sodium Colistin 2012
Ceftaroline Cephalosporines 2010 2012

However, the world’s capacity for antibiotic discovery is already reducing the rate of emergence of bacterial resistance, and which indicates the necessity of another new class of antibiotics to be introduced in the market (Figure1). Fig. 1 showed a line drawing of total number of newer classes of antibiotics that entered to the market in the years of 1940s and 1960s, the two new classes since 2000, and further 20-40 new classes were required to support medicine in the future years from now [6].

Fig. 1: Number of antibiotics in the market and the predictions of new antibiotics needed for the future

Novel antibiotics in recent years

The majority of new antibiotic substances is in the early phase of development is, phase 1 clinical trials [4]. The clinical trials for new antibiotics are believed to be cover disease indications even if it is the infection caused by more than one bacterial species [14]. The research updates showed that only two new classes of antibiotics were marketed in last 10 y and it may be due to the lack of development and almost all the pharmaceutical companies were concentrating only on analogue development which may be due to the high toxicity risks associated with the new classes [15]. At present, the environment has changed a little positively, and those who observing preclinical and clinical development strategies and activities have a reason to be more optimistic [11].

Several compounds have been developed in various antibiotic classes which are against resistant organisms in the whole spectrum of multidrug-resistant (MDR) bacteria (fig. 2) [11].

Fig. 2: New antibiotic compounds acting against resistant organisms

Source Reference: https:/ diagram [16]

Since most of the infections can be cured without antibiotic therapy, thus, new antibiotic approval is generally limited to complicated or more serious infections. The Infectious Diseases Society of America (IDSA) emphasizes that selecting the optimal drug regimen; dose, duration, and route of administration are a very important part in the stewardship practice. Furthermore, stewardship seeks to diminish the toxicity and other adverse events and also to lessen the costs of healthcare infections [16].

It is not easy to estimate the numbers of drugs in preclinical development, as most of them are not published or marketed [17]. Still, there are no antibiotics against the major gram-negative microorganisms such as K. pneumoniae, P. aeruginosa and A. baumanii in Phase II b and III and also the number of compounds (analogs of existing markets antibiotics) against these pathogenic organisms in earlier stages of development are also lessened. Since there are no new classes of antibiotics in the final phases of drug development, the new class antibiotics will not be introduced in the market in the short term [10, 18]. In the longer term, during the next 20 y, the probability of inventing twenty new antibiotic classes like many broad-spectrum antibiotics, as similar in 1940-1960s, looks to be remote, especially for multi-drug-resistant gram-negative microorganisms.

Novel compounds against microorganisms which are under clinical development

• Compounds against Gram-positive bacteria

Novel long-acting lipoglycopeptides-oritavancin and dalbavancin

Acute bacterial skin and skin structure infections (ABSSIs) are considered as the major bacterial infection and the frequent indications for antibacterial therapy, which are usually induced by Gram-positive bacteria like MRSA (Methicillin-resistant Staphylococcus aureus). With the introduction of the newer lipoglycopeptides with an extended elimination half-life, ABSSSI therapy may become more convenient. Oritavancin acts by inhibiting transglycosylation (like vancomycin), transpeptidation (like beta-lactams), and disruption of cell membrane integrity (like telavancin) [19] and results in quick bactericidal activity. It has a long elimination half-life of>300 h [20] and showed a strong bactericidal activity in a dose of 1200 mg in the in vitro PK/PD model [21].

Dalbavancin is another semisynthetic lipoglycopeptide which has been estimated for skin and soft tissue/skin structure infections, [22, 23] and also for catheter-associated bloodstream infections. Its half-life is about two weeks [24] also allowed for prolonged dosing intervals. Dalbavancin had a favorable safety profile with fewer adverse effects. It is estimated that the usage of dalbavancin was joined up with a significantly lower mortality (0.2 vs. 1.1 %). Finally, this has proceeded to the FDA approval of dalbavancin for ABSSSI caused by S. Aureus and S. pyogenes in May 2014.

Drugs to destroy gram-negative bacteria and broad-spectrum antibiotics


BAL30072 is a monosulfactam antibiotic, have an action against carbapenem-resistant Enterobacteriaceae and non-ferments [25]. It is chemically related to aztreonam and coming under the class of beta-lactam antibiotic and inhibiting the cell wall synthesis of bacteria. Certain in vitro studies has shown that the combination of BAL30072 with BAL29880 or clavulanate can result in susceptibility rates of more than 90%. A study conducted in Thailand, with its laboratory strains (1026b, 1710b) and several strains which are isolated, it was observed that more than 93% of the isolates were susceptible to BAL30072 with minimal inhibitory concentrations (MICs) between 0.004-0.016 μg/ml [26]. BAL30072 showed high activity through a MIC 90 of 0.016 μg/ml as compared to ceftazidime, meropenem, and imipenem.


Ceftolozane with tazobactam is presently undergoing certain investigational studies for testing its action in complicated urinary tract infections (cUTIs), complicated intra-abdominal infections (cIAIs) and ventilator-associated pneumonia (VAP). It is a new cephalosporin which is structurally similar to ceftazidime, which active against Pseudomonas and also against bacteria-producing beta-lactamases such as TEM-1. [11] Ceftolozanealone cannot destoy or kill the bacteria-producing ESBL and carbapenemases. However, along with tazobactam, it can destroy most of the bacteria-producing ESBL and some anaerobes. The FDA approved ceftolozane/ tazobactam to treat adultscIAI and cUTI in December 2014 [27].

Delafloxacin (fluoroquinolone)

Delafloxacin is a fluoroquinolone and its efficacy is undergoing through various investigational studies. As compared with others, it has a substituent on the seventh position of the quinoline ring system which is not protonatable and causes a pKa shift. Generally fluoroquinolones are zwitterionic except delafloxacin and as a result, they are neutrally charged only at a physiological pH. The neutral charge is essential for membrane penetration. Delafloxacin permeates the membranes at lower pH as seen in the inflamed tissue [28, 29]. Generally, the pH levels are mildly acidic (about 5.5-6) in the inflammatory tissue of soft tissue infections, abdominal infections, or urinary tract infections, under these conditions, e. g., 90% of moxifloxacin is in a cationic state, so it cannot permeate the bacterial membranes. In contrast, delafloxacin is neutral at this pH and thereby leads to high cellular uptake [28].

Novel beta-lactamase inhibitors

The beta-lactamase inhibitors which are available for the clinical application includes sulbactam, clavulanate, tazobactam, etc. Recently, these beta-lactamases increases the resistance particularly to Gram-negative bacillieg. oxacillinasescephalosporinases and the metallo-beta-lactamases. Novel beta-lactamase inhibitors (e. g., diazabicyclooctane-related substances) are also able to inhibit these enzymes to a different extent. They, therefore, contribute substantially to meet the increasing need for new drugs against ESBL or Klebsiella pneumonia carbapenemases (KPCs)-producing bacilli [11].

Antibiotics currently under clinical development

SinceMarch 2017, about 41 novel antibiotics have been found to be under clinical investigation in the U. S. market for the management of potential bacterial infections. The achievement rate for such clinical drug development is low; the various study data showed that, generally, only 1 in 5 infectious disease products are entering into phase 1 clinical trial (human testing) [30]. The present antibiotic pipeline, on the basis of currently available information, is given in table 3. It will be revised in a periodic manner.

Table 3: List of compounds which are under clinical development

Drug name Company Drug class Target Expected activity against resistantGram-negativeESKAPE pathogens Expected activity against a CDCurgent threat pathogen Potential Indications




Melinta Therapeutics Inc.

Rempex Phar maceuticalsInc

Crestone Inc.


β-lactam (carbapenem)+β-lactamase inhibitor(cyclic boronate)


Bacterial type IITopoisomerase

PBP; β-lactamase

MethionylTrnasynthetase [17]






ABSSIs, cUTI, Community-acquired pneumonia (CAP) [6]

cUTI, cIAIs, Hospital-acquired bacterial pneumonia/ventilator associated bacterial pneumonia,Febrile neutropenia, Bacteremia.[6]

C. difficileinfections

ETX2514SUL10 Entasis Therapeutics Inc. β-lactam (sulbactam)+β-lactamase inhibitor(diazabicyclooctane) PBP; β-lactamase Yes No Bacterial infections (caused byAcinetobacterbaumannii) [6]
GSK-334283010 GlaxoSmithKlinePLC (Shionogilicensee) β-lactam (cephalosporin) PBP Possibly Possibly Bacterial infections
KBP-7072 KBPBioSciencesPharmaceuticalTechnical Co. Ltd. Tetracycline 30S subunit ofbacterial ribosome Possibly No CAP [6]
LCB01-037110 LegoChemBiosciences Inc. Oxazolidinone 50S subunit ofbacterial ribosome No No Bacterial infections
MCB3837 Morphochem AG Oxazolidinone-quinolonehybrid 50S subunit of bacterial ribosome; bacterial type IItopoisomerase No Yes C. difficile infections[6]
MGB-BP-310 MGBBiopharmaLtd. Distamycin [16] DNA minor groove No Yes C. difficile-associated diarrhea
Nacubactam (OP0595/RG6080) Meiji Seika PharmaCo. Ltd./FedoraPharmaceuticalsInc. (Rochelicensee) β-lactamase inhibitor(diazabicyclooctane) β-lactamase, PBP2 Possibly Possibly Bacterial infections
SPR74 Spero Therapeutics Polymyxin Cell membrane Possibly Possibly Bacterial infections
TD-1607 TheravanceBiopharma Inc. Glycopeptide-β-lactam(cephalosporin) hybrid PG chainelongation; PBP No No ABSSIs, hospital-acquired pneumonia/ventilator-associated bacterial pneumonia, bacteremia. [6]
TP-271 TetraphasePharmaceuticals inc Tetracycline 30S subunit ofbacterial ribosome Possibly Possibly Community-acquired bacterial pneumonia
TP-60766 TetraphasePharmaceuticals Inc Tetracycline 30S subunit ofbacterial ribosome Possibly Possibly Bacterial infections
WCK 2349 Wockhardt Ltd. Fluoroquinolone (WCK771 pro-drug) Bacterial type IItopoisomerase No No Hospital-acquired bacterial pneumonia [6]
WCK 771 Wockhardt Ltd. Fluoroquinolone Bacterial type IItopoisomerase No No Hospital-acquired bacterial pneumonia [6]
Cefepime+Zidebactam(WCK 5222) Wockhardt Ltd. β-lactam (cephalosporin)+β-lactamase inhibitor(diazabicyclooctane) PBP; β-lactamase Yes Possibly cUTIs,hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia[6]
Aztreonam+Avibactam [7,10](ATM-AVI) Pfizer Inc./AllerganPLC β-lactam (monobactam)+β-lactamase inhibitor(diazabicyclooctane) PBP; β-lactamase Yes Yes cIAIs
Brilacidin Cellceutix Corp. Defensin mimetic16 Cell membrane No No ABSSIs
CG400549 CrystalGenomicsInc. Benzyl pyridinone Fab1 inhibitor No No ABSSIs, osteomyelitis [6]
Afabicin(Debio 1450) DebiopharmInternational SA Benzofurannaphthyridine Fab1 inhibitor No No ABSSIs and osteomyelitis (Staphylococcus-specific)
Finafloxacin MerLionPharmaceuticalsPvt Ltd. Fluoroquinolone Bacterial type II topoisomerase Yes Possibly cUTIs, acute pyelonephritis, cIAIs, ABSSIs
Gepotidacin(GSK2140944)15 GlaxoSmithKlinePLC Triazaacenaphthylene[16] Bacterial type II topoisomerase(novel A subunitsite)
No Yes cUTIs, uncomplicatedUTI, ABSSIs uncomplicated urogenital gonorrhoeaand CAP [6]
MRX-I 14 - - 50S subunit of bacterial ribosome No No ABSSIs
Nafithromycin (WCK 4873) Wockhardt Ltd. Macrolide 50S subunit of bacterial ribosome No No CAP
Nemonoxacin TaiGenBiotechnology Co. Ltd. Quinolone Bacterial type IItopoisomerase No No CAP, diabetic foot infection, ABSSIs
Murepavadin (POL7080) Polyphor Ltd. Antimicrobial peptide mimetic  Targeting Pseudomonas LPS-assembly protein (OstA; LptD; Imp) Yes (Pseudomonas) No Ventilator-associated bacterial pneumonia (caused by Pseudomonas aeruginosa), lower respiratory tract infection, Bronchiectasis
Ramoplanin NanotherapeuticsInc. Lipodepsipeptide Lipid I,II No Yes C. difficile infection[6]
Ridinilazole(SMT 19969) SummitTherapeutics Inc. Bis-benzimidazole[1] Unknown No Yes C. difficile infection [26]
Zoliflodacin(ETX0914) EntasisTherapeutics Inc. Spiropyrimidenetrione[16] Bacterial type IItopoisomerase(GyrB) No Yes Uncomplicated gonorrhea
Cadazolid ActelionPharmaceuticalsLtd. Oxazolidinone-quinolonehybrid 50S subunit of bacterial ribosome; bacterial type Iitopoisomerase No Yes C. difficile infection
Cefiderocol (S-649266)30 Shionogi and Co. Ltd. Siderophore-β-lactam(cephalosporin) PBP Yes Yes cUTI, carbapenem-resistant Gram-negative bacterial infections
Eravacycline TetraphasePharmaceuticalsInc. Tetracycline 30S subunit of bacterial ribosome Yes Yes cIAIs, cUTI
Iclaprim Motif Bio PLC 2,4 diaminopyrimidine Dihydrofolatereductase No No ABSSIs, hospital-acquired bacterial pneumonia
Imipenem/cilastatin+relebactam (MK-7655) Merck and Co. Inc. β-lactam (carbapenem)+β-lactamase inhibitor(diazabicyclooctane) PBP; β-lactamase Yes Yes cUTI,Acutepyelonephritis, cIAIs,hospital-acquired bacterial pneumonia/ventilator-associated bacterial pneumonia
Lefamulin (BC-3781) NabrivavTherapeutics AG Pleuromutilin[16] 50S subunit ofbacterial ribosome No No ABSSIs,CAP, hospital-acquired bacterial pneumonia/ventilator-associatedbacterial pneumonia, Osteomyelitis, prosthetic jointinfections [6]
Omadacycline ParatekPharmaceuticalsInc. Tetracycline 30S subunit of bacterial ribosome Yes Possibly CAP, ABSSIs


There are many promising antibiotic compounds which are currently under clinical development which will be open up the possibilities for treating various life-threatening infections, but among them very few are reaching the stage of human testing. The resistance mechanisms are the main problem associated with the antibiotic therapy, but this will not stop with the entry of the new drugs into the market. Therefore, the race must continue, and drugs with new actions need to be investigated and tested for human use. The requirements should include that, the product is within the scope of combination regimes, should be made possible as this could help to delay the development of resistance.


All the author have contributed equally


Declared none


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Antibiotics, Clinical development, Narrow spectrum





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International Journal of Applied Pharmaceutics
Vol 10, Issue 3 (May-Jun), 2018 Page: 13-18

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Authors & Affiliations

Niranjana E. S.
Department of Pharmacy Practice, J. K. K. Nattraja College of Pharmacy, Kumarapalayam 638183

Sambath Kumar R.
Department of Pharmaceutics, J. K. K. Nattraja College of Pharmacy, Kumarapalayam 638183

Sudha M.
Department of Pharmacology, J. K. K. Nattraja College of Pharmacy, Kumarapalayam 638183

Venkateswaramurthy N.
Department of Pharmacy Practice, J. K. K. Nattraja College of Pharmacy, Kumarapalayam 638183


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