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Mechanism Of Action
Ceftaroline is a cephalosporin antibacterial [see Microbiology].
As with other beta-lactam antimicrobial agents, the time that unbound plasma concentration of ceftaroline exceeds the minimum inhibitory concentration (MIC) of the infecting organism has been shown to best correlate with efficacy in a neutropenic murine thigh infection model with S. aureus and S. pneumoniae.
Exposure-response analysis of Phase 2/3 ABSSSI trials supports the recommended dosage regimen of Teflaro 600 mg every 12 hours by IV infusion over 1 hour. For Phase 3 CABP trials, an exposure-response relationship could not be identified due to the limited range of ceftaroline exposures in the majority of patients.
In a randomized, positive- and placebo-controlled crossover thorough QTc study, 54 healthy subjects were each administered a single dose of Teflaro 1500 mg, placebo, and a positive control by IV infusion over 1 hour. At the 1500 mg dose of Teflaro, no significant effect on QTc interval was detected at peak plasma concentration or at any other time.
The mean pharmacokinetic parameters of ceftaroline in healthy adults (n=6) with normal renal function after single and multiple 1-hour IV infusions of 600 mg ceftaroline fosamil administered every 12 hours are summarized in Table 5. Pharmacokinetic parameters were similar for single and multiple dose administration.
Table 5: Mean (Standard Deviation) Pharmacokinetic
Parameters of Ceftaroline IV in Healthy Adults
|Parameter||Single 600 mg Dose Administered as a 1-Hour Infusion
|Multiple 600 mg Doses Administered Every 12 Hours as 1-Hour Infusions for 14 Days
|Cmax (mcg/mL)||19.0 (0.71)||21.3 (4.10)|
|Tmax (h)a||1.00 (0.92-1.25)||0.92 (0.92-1.08)|
|AUC (mcg•h/mL) b||56.8 (9.31)||56.3 (8.90)|
|T½ (h)||1.60 (0.38)||2.66 (0.40)|
|CL (L/h)||9.58 (1.85)||9.60 (1.40)|
|a Reported as median (range)
b AUC0-∞, for single-dose administration; AUC0-tau, for multiple-dose administration; Cmax, maximum observed concentration; Tmax, time of Cmax; AUC0-∞, area under concentration-time curve from time 0 to infinity; AUC0-tau, area under concentration-time curve over dosing interval (0-12 hours); T½, terminal elimination half-life; CL, plasma clearance
The Cmax and AUC of ceftaroline increase approximately in proportion to dose within the single dose range of 50 to 1000 mg. No appreciable accumulation of ceftaroline is observed following multiple IV infusions of 600 mg administered every 12 hours for up to 14 days in healthy adults with normal renal function.
The systemic exposure (AUC), T½, and clearance of ceftaroline were similar following administration of 600 mg ceftaroline fosamil in a volume of 50 mL to healthy subjects every 8 hours for 5 days as 5-minute or 60-minute infusions, and the Tmax of ceftaroline occurred about 5 minutes after the end of the ceftaroline fosamil infusion for both infusion durations. The mean (SD) Cmax of ceftaroline was 32.5 (4.82) mcg/mL for the 5-minute infusion duration (n=11) and 17.4 (3.87) mcg/mL for the 60-minute infusion duration (n=12).
The average binding of ceftaroline to human plasma proteins is approximately 20% and decreases slightly with increasing concentrations over 1-50 mcg/mL (14.5-28.0%). The median (range) steady-state volume of distribution of ceftaroline in healthy adult males (n=6) following a single 600 mg IV dose of radiolabeled ceftaroline fosamil was 20.3 L (18.3-21.6 L), similar to extracellular fluid volume.
Ceftaroline fosamil is the water-soluble prodrug of the bioactive ceftaroline. Ceftaroline fosamil is converted into bioactive ceftaroline in plasma by a phosphatase enzyme and concentrations of the prodrug are measurable in plasma primarily during IV infusion. Hydrolysis of the beta-lactam ring of ceftaroline occurs to form the microbiologically inactive, open-ring metabolite ceftaroline M-1. The mean (SD) plasma ceftaroline M-1 to ceftaroline AUC0-∞ ratio following a single 600 mg IV infusion of ceftaroline fosamil in healthy adults (n=6) with normal renal function is 28% (3.1%).
When incubated with pooled human liver microsomes, ceftaroline was metabolically stable ( < 12% metabolic turnover), indicating that ceftaroline is not a substrate for hepatic CYP450 enzymes.
Ceftaroline and its metabolites are primarily eliminated by the kidneys. Following administration of a single 600 mg IV dose of radiolabeled ceftaroline fosamil to healthy male adults (n=6), approximately 88% of radioactivity was recovered in urine and 6% in feces within 48 hours. Of the radioactivity recovered in urine approximately 64% was excreted as ceftaroline and approximately 2% as ceftaroline M-1. The mean (SD) renal clearance of ceftaroline was 5.56 (0.20) L/h, suggesting that ceftaroline is predominantly eliminated by glomerular filtration.
Following administration of a single 600 mg IV dose of Teflaro, the geometric mean AUC0-∞ of ceftaroline in subjects with mild (CrCl > 50 to ≤ 80 mL/min, n=6) or moderate (CrCl > 30 to ≤ 50 mL/min, n=6) renal impairment was 19% and 52% higher, respectively, compared to healthy subjects with normal renal function (CrCl > 80 mL/min, n=6). Following administration of a single 400 mg IV dose of Teflaro, the geometric mean AUC0-∞ of ceftaroline in subjects with severe (CrCl ≥ 15 to ≤ 30 mL/min, n=6) renal impairment was 115% higher compared to healthy subjects with normal renal function (CrCl > 80 mL/min, n=6). Dosage adjustment is recommended in patients with moderate and severe renal impairment [see DOSAGE AND ADMINISTRATION].
A single 400 mg dose of Teflaro was administered to subjects with ESRD (n=6) either 4 hours prior to or 1 hour after hemodialysis (HD). The geometric mean ceftaroline AUC0-∞ following the post-HD infusion was 167% higher compared to healthy subjects with normal renal function (CrCl > 80 mL/min, n=6). The mean recovery of ceftaroline in the dialysate following a 4-hour HD session was 76.5 mg, or 21.6% of the administered dose. Dosage adjustment is recommended in patients with ESRD (defined as CrCL < 15 mL/min), including patients on HD [see DOSAGE AND ADMINISTRATION].
The pharmacokinetics of ceftaroline in patients with hepatic impairment have not been established. As ceftaroline does not appear to undergo significant hepatic metabolism, the systemic clearance of ceftaroline is not expected to be significantly affected by hepatic impairment.
Following administration of a single 600 mg IV dose of Teflaro to healthy elderly subjects ( ≥ 65 years of age, n=16), the geometric mean AUC0-∞ of ceftaroline was ~33% higher compared to healthy young adult subjects (18-45 years of age, n=16). The difference in AUC0-∞ was mainly attributable to age-related changes in renal function. Dosage adjustment for Teflaro in elderly patients should be based on renal function [see DOSAGE AND ADMINISTRATION].
The pharmacokinetics of ceftaroline were evaluated in adolescent patients (ages 12 to 17, n=7) with normal renal function following administration of a single 8 mg/kg IV dose of Teflaro (or 600 mg for subjects weighing > 75 kg). The mean plasma clearance and terminal phase volume of distribution for ceftaroline in adolescent subjects were similar to healthy adults (n=6) in a separate study following administration of a single 600 mg IV dose. However, the mean Cmax and AUC0-∞ for ceftaroline in adolescent subjects who received a single 8 mg/kg dose were 10% and 23% less than in healthy adult subjects who received a single 600 mg IV dose.
Following administration of a single 600 mg IV dose of Teflaro to healthy elderly males (n=10) and females (n=6) and healthy young adult males (n=6) and females (n=10), the mean Cmax and AUC0-∞ for ceftaroline were similar between males and females, although there was a trend for higher Cmax (17%) and AUC0-∞ (615%) in female subjects. Population pharmacokinetic analysis did not identify any significant differences in ceftaroline AUC0-tau based on gender in Phase 2/3 patients with ABSSSI or CABP. No dose adjustment is recommended based on gender.
A population pharmacokinetic analysis was performed to evaluate the impact of race on the pharmacokinetics of ceftaroline using data from Phase 2/3 ABSSSI and CABP trials. No significant differences in ceftaroline AUC0-tau was observed across White (n=35), Hispanic (n=34), and Black (n=17) race groups for ABSSSI patients. Patients enrolled in CABP trials were predominantly categorized as White (n=115); thus there were too few patients of other races to draw any conclusions. No dosage adjustment is recommended based on race.
No clinical drug-drug interaction studies have been conducted with Teflaro. There is minimal potential for drug-drug interactions between Teflaro and CYP450 substrates, inhibitors, or inducers; drugs known to undergo active renal secretion; and drugs that may alter renal blood flow.
In vitro studies in human liver microsomes indicate that ceftaroline does not inhibit the major cytochrome P450 isoenzymes CYP1A1, CYP1A2, CYP2A6, CYP2B6, CYP2C8, CYP2C9, CYP2C19, CYP2D6, CYP2E1 and CYP3A4. In vitro studies in human hepatocytes also demonstrate that ceftaroline and its inactive open-ring metabolite are not inducers of CYP1A2, CYP2B6, CYP2C8, CYP2C9, CYP2C19, or CYP3A4/5. Therefore Teflaro is not expected to inhibit or induce the clearance of drugs that are metabolized by these metabolic pathways in a clinically relevant manner.
Population pharmacokinetic analysis did not identify any clinically relevant differences in ceftaroline exposure (Cmax and AUC0-tau) in Phase 2/3 patients with ABSSSI or CABP who were taking concomitant medications that are known inhibitors, inducers, or substrates of the cytochrome P450 system; anionic or cationic drugs known to undergo active renal secretion; and vasodilator or vasoconstrictor drugs that may alter renal blood flow.
Mechanism of Action
Ceftaroline is a cephalosporin with in vitro activity against Gram-positive and -negative bacteria. The bactericidal action of ceftaroline is mediated through binding to essential penicillin-binding proteins (PBPs). Ceftaroline is bactericidal against S. aureus due to its affinity for PBP2a and against Streptococcus pneumoniae due to its affinity for PBP2x.
Ceftaroline is not active against Gram-negative bacteria producing extended spectrum beta-lactamases (ESBLs) from the TEM, SHV or CTX-M families, serine carbapenemases (such as KPC), class B metallobeta-lactamases, or class C (AmpC cephalosporinases).
Although cross-resistance may occur, some isolates resistant to other cephalosporins may be susceptible to ceftaroline.
Interaction with Other Antimicrobials
In vitro studies have not demonstrated any antagonism between ceftaroline or other commonly used antibacterial agents (e.g., vancomycin, linezolid, daptomycin, levofloxacin, azithromycin, amikacin, aztreonam, tigecycline, and meropenem).
Ceftaroline has been shown to be active against most of the following bacteria, both in vitro and in clinical infections [see INDICATIONS AND USAGE].
Staphylococcus aureus (including methicillin-susceptible
and -resistant isolates)
Community-Acquired Bacterial Pneumonia (CABP)
Staphylococcus aureus (methicillin-susceptible isolates only)
The following in vitro data are available, but their clinical significance is unknown. At least 90 percent of the following bacteria exhibit an in vitro minimum inhibitory concentration (MIC) less than or equal to the susceptible breakpoint for ceftaroline against isolates of similar genus or organism group. However, the efficacy of ceftaroline in treating clinical infections due to these bacteria has not been established in adequate and well-controlled clinical trials.
Susceptibility Test Methods
When available, the clinical microbiology laboratory should provide the results of in vitro susceptibility test results for antimicrobial drugs used in local hospitals and practice areas to the physician as periodic reports that describe the susceptibility profile of nosocomial and community-acquired pathogens. These reports should aid the physician in selecting an antibacterial drug product for treatment.
Quantitative methods are used to determine antimicrobial minimum inhibitory concentrations (MICs). These MICs provide estimates of the susceptibility of bacteria to antimicrobial compounds. The MICs should be determined using a standardized test method1,3, (broth, and/or agar). Broth dilution MICs need to be read within 18 hours due to degradation of ceftaroline activity by 24 hours. The MIC values should be interpreted according to the criteria in Table 6.
Quantitative methods that require measurement of zone diameters can also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. The zone size provides an estimate of the susceptibility of bacteria to antimicrobial compounds. The zone size should be determined using a standardized method. This procedure uses paper disks impregnated with 30 mcg of ceftaroline to test the susceptibility of bacteria to ceftaroline. The disk diffusion interpretive criteria are provided in Table 6.
Table 6: Susceptibility Interpretive Criteria for
|Pathogen and Isolate Source||Minimum Inhibitory Concentrations (mcg/mL)||Disk Diffusion Zone Diameter (mm)|
|Staphylococcus aureus (includes methicillin-resistant isolates - skin isolates only) -See NOTE below||≤ 1||2||≥ 4||≥ 24||21-23||≤ 20|
|Streptococcus agalactiaea (skin isolates only)||≤ 0.5||—||—||≥ 26||—||—|
|Streptococcus pyogenesa (skin isolates only)||≤ 0.5||—||—||≥ 26||—||—|
|Streptococcus pneumoniaea (CABP isolates only)||≤ 0.5||—||—||≥ 26||—||—|
|Haemophilus influenzaea (CABP isolates only)||≤ 0. 5||—||—||≥ 30||—||—|
|Enterobacteriaceae b (CABP and skin isolates)||≤ 0.5||1||≥ 2||≥ 23||20-22||≤ 19|
|S = susceptible, I =
intermediate, R = resistant
NOTE: Clinical efficacy of Teflaro to treat lower respiratory infections such as community-acquired bacterial pneumonia due to MRSA has not been studied in adequate and well controlled trials (See “Clinical Trials” section 14)
a The current absence of resistant isolates precludes defining any results other than “Susceptible.” Isolates yielding MIC results other than “Susceptible” should be submitted to a reference laboratory for further testing.
b Clinical efficacy was shown for the following Enterobacteriaceae: Escherichia coli, Klebsiella pneumoniae, and Klebsiella oxytoca.
A report of Susceptible(S) indicates that the antimicrobial drug is likely to inhibit growth of the pathogen if the antimicrobial drug reaches the concentration usually achievable at the site of infection. A report of Intermediate (I) indicates that the result should be considered equivocal, and if the microorganism is not fully susceptible to alternative clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where a high dosage of the drug can be used. This category also provides a buffer zone that prevents small uncontrolled technical factors from causing major discrepancies in interpretation. A report of Resistant (R) indicates that the antimicrobial drug is not likely to inhibit growth of the pathogen if the antimicrobial drug reaches the concentrations usually achievable at the infection site; other therapy should be selected.
Standardized susceptibility test procedures require the use of laboratory controls to monitor and ensure the accuracy and precision of supplies and reagents used in the assay, and the techniques of the individuals performing the test.1,2, 3 Standard ceftaroline powder should provide the following range of MIC values provided in Table 7. For the diffusion technique using the 30-mcg ceftaroline disk the criteria provided in Table 7 should be achieved.
Table 7: Acceptable Quality Control Ranges for
|Quality Control Organism||Minimum Inhibitory Concentrations (mcg/mL)||Disk Diffusion (zone diameters in mm)|
|Staphylococcus aureus ATCC 25923||Not Applicable||26-35|
|Staphylococcus aureus ATCC 29213||0.12-0.5||Not Applicable|
|Escherichia coli ATCC 25922||0.03-0.12||26-34|
|Haemophilus influenzae ATCC 49247||0.03-0.12||29-39|
|Streptococcus pneumoniae ATCC 49619||0.008-0.03||31-41|
|ATCC = American Type Culture Collection|
Last reviewed on RxList: 9/15/2015
This monograph has been modified to include the generic and brand name in many instances.
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