TIGECYCLINE

A NEW WEAPON AGAINST ANTIBACTERIAL RESISTANCE

Adam Corey

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As soon as Alexander Fleming accidentally discovered the medicinal benefit of antibiotics, bacteria
began fighting back. Penicillin appeared as the kind of magic bullet Paul Ehrlich envisioned, but the ability
of microbes to evolve resistance mechanisms has led to an evolutionary and pharmacological arms race
over the last century. Antibiotics attack susceptible bacteria through specific mechanisms based on the
cellular and metabolic differences between prokaryotes and eukaryotes. One class of antibiotics, the
tetracyclines, prevents the synthesis of new proteins by binding to the bacterial ribosomes. Unfortunately,
the bacteria responded by modifying their ribosomes and pumping the antibiotic out of the cell.
1
Tigecycline,
a glycycline built of the tetracycline scaffold, possesses a unique functional group that allows it to block the
bacterial ribosome and simultaneously evade bacterial resistance mechanisms.
2
Developed under the name
GAR-936 by Wyeth Pharmaceuticals in Philadelphia, tigecycline (brand name: Tygacil) provides a new
weapon in the rapidly changing battle of antibacterial resistance.
As a new tetracycline, tigecycline uses the same mechanism of action of its tetracycline ancestors
preventing protein synthesis. Invading bacteria require new proteins to survive, which are made by
ribosomes. A copy of the genetic information is transcribed into an RNA message that can be translated by
a ribosome. During the translational process, the mRNA feeds between the two subunits presenting the
codon that determines the appropriate amino acid to be added to the growing peptide chain. The transfer
RNA (tRNA) with the correct anticodon enters into the A-site with the specified amino acid. From here, the
amino-acyl-tRNA pivots to the P-site for the peptidyl-transfer reaction.
2
After attaching, the tRNA slides to
the E-site and ejects from the ribosome as a new aminoacyl-tRNA enters to continue the elongation of the
peptide chain.
Tetracyclines and tigecycline specifically target the 30S subunit of the bacterial ribosome by binding
reversibly to the A-site, and preventing the accommodation of the tRNA.
3
Within the 30S subunit,
tetracylines interfere with the H34 helical region of the 16S rRNA through hydrogen bonds between the
hydrophilic parts of the drug and the phosphate backbone. The resulting steric hindrance prevents
aminoacyl-tRNA from pivoting to the P-site and blocks the elongation of the peptide chain. While
tetracyclines bind to the subunit in one direction, tigecycline blocks the A-site although through a different
orientation. This unique binding increases tigecyclines affinity almost 5-fold giving the antibiotic its
bacteriostatic properties and a method of circumventing the resistance proteins in some strains of bacteria.
2

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All antibiotic products face the challenge of bacterial resistance. Formerly susceptible bacterial strains
employ two major resistance mechanisms against tetracycline antibiotics. First, bacteria up-regulate efflux
pumps to expel the harmful antibiotics from the cell before it can perform its inhibitory activity. When Gram-
negative bacteria encounter a tetracycline product, efflux genes known in sequence as TetA-E turn on to a
decrease the concentration of drug within the cell. Gram-positive bacteria remove tetracyclines through the
same efflux process, but with the genes TetG-L. These gram-positive bacteria also produce extra small
proteins that block the location of tetracycline binding through the genes TetM or TetO.
1,4
The protective
proteins compete with the tetracycline and reduce the effectiveness of the drug. Researchers designed
tigecycline with the intention of avoiding the Tet efflux pumps by including a bulky side chain that would stay
in the cell to continue working, but they also found that it continued to work in the presence TetM proteins
During development in the early 1990s, tigecycline became the main focus of a new antibiotic class of
glycyclines that retained the ribosome blocking mechanisms of tetracycline but avoided the evolved Tet
resistance.
4
Starting with tetracyclines four-ring structure, researchers developed new generations of
antibiotics by attaching various functional groups to evade efflux and avoid TetM proteins. For example,
doxycycline moves a hydroxyl group from the C-ring to the B-Ring, while minocycline includes a
dimethylamine to the 7-position on the D-ring (See Figure 1). Minocycline proved to be a strong antibiotic,
but eventually succumbed to similar mechanisms of resistance. Researchers attempted to improve
minocycline by including a new functional group to C-9 position of the D-ring. An early glycycline,
dimethylglycylamido-minocycline (DMG-MINO) provided a hopeful avenue, but tigecycline showed the most
promise against the more clinically relevant, multidrug resistant pathogens.
5,6
Structurally, tigecycline, a
chemical descendant of minocycline, adds a tert-butyl-glycylamido group to the D-Ring, which provides the
anti-resistance benefits while maintaining antibacterial properties with three main improvements. First, the
molecule became more lipophilic allowing for easier transport into the cell. Because tetracyclines act on
ribosomes, they must reach the cytosol to perform their inhibitory mechanisms. The additional side chain
increases tigecyclines volume of distribution to 7-9 L/kg, showing that more of the drug resides tissues than
in plasma.
3
Secondly, the extra-long alkyl group creates enough steric hindrance to prevent efflux from the
cell. Where tetracyclines would be removed, the bulky tigecycline continues to work. Thirdly, tigecycline
shows five times more affinity to the 30S ribosome compared to tetracycline.
2
The 9-tert-butyl-glycylamido
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group shifts the orientation of tigecycline within the 30S ribosome and generates more stable hydrogen bond
stacking, shielding the molecule from TetM protective proteins.
7,8
The important glycylamido addition to the
minocycline backbone provides the biochemical opportunity for the pharmacological improvements of
tigecycline over minocycline and other tetracyclines. Unfortunately, some anaerobic bacteria have displayed
resistance to tigecycline through the upregulation of a different set of efflux pumps. Enterobacter and
Acinetobacter increase the number of RND pumps on their membranes, which are not blocked by the bulky
side chain and remove tigecycline from the cell.
2

Interest in tigecycline led to worldwide testing process as many countries sponsored research into the
effectiveness of tigecycline through the TEST Program (Tigecycline Evaluation and Surveillance Trial).
Tigecycline showed similar or improved results to treatment by minocycline (the closest relative), to a
vancomycin-azetrenam combination, and to an imipenem-cilastatin combination (See Figure 2 and 3).
Specifically, tigecycline provides hope to treat the various drug-resistant strains like vancomycin-resistant
Enterococci (VRE), methicillin-resistant Staphalococcus aureus (MRSA), penicillin-resistant Streptococcus
pneumonia, and beta-lactamase producing E. coli. However, the TEST program has shown regional
variations in the activities of tigecycline against resistant bacteria and a growing resistance to tigecycline
itself.

The FDA approved tigecycline for the treatment of complicated intra-abdominal infections, community-
acquired bacterial pneumonia, and complicated skin infections against a wide range of species.
3,4,9
The FDA
Black Box Warning suggests a 0.6% increase in morality risk and advises the use of tigecycline only when
alternatives are not available.
9

Unsusceptible to the normal methods of tetracycline resistance, tigecycline continues to inhibit the 30S
ribosomal subunit despite Tet efflux transporters or TetM proteins that protect the accommodation site of the
ribosome. Tigecycline demonstrates the creative ability biochemistry provides to overcome bacterial
resistance by building on the structure of minocycline. Tigecyclines bulky side chain generates the improved
characteristics of tigecycline. At this point, tigecycline remains the only FDA approved glycycline and offers a
potent weapon against antibacterial resistance.



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References
1. Projan S. Preclinical pharmacology of GAR-936, a novel glycycline antibacterial agent.
Pharmacotherapy. 2000;20(9):219-223.

2. Seputiene V, Povilonis J, Armalyte J, Suziedelis K, Pavilonis A, Suziedeliene E. Tigecycline - how
powerful is it in the fight against antibiotic-resistant bacteria? Medicina (Kaunas). 2010;46(4):240-
248.

3. Doan T, Fung H, Mehta D, Riska P. Tigecycline: A glycylcyline antimicrobial agent. Clin Thera.
2006;28(8):1079-1106.

4. Peterson L. A review of tigecycline - the first glycycline. International Journal of Antimicrobial
Agents. 2008;32(S4):S215-S222.

5. Garrison M, Neumiller J, Setter S. Tigecycline: An investigational glycycline antimicrobial with
activity against resistant gram-positive organisms. Clin Thera. 2005;27(1):12-22.

6. Loh E, Ellis-Grosse E, Petersen P, Sum P, Projan S. Tigecycline: A case study. Expert Opin Drug
Discov. 2007;2(3):403-418.

7. Olson M, Ruzin A, Feyfant E, Rush T, O'Connell J, Bradford P. Functional, biophysical, and structural
bases for antibacterial activity of tigecycline. Antimicrob Agents Chemother. 2006;50(6):2156-2166.

8. Jenner L, Starosta A, Terry D, et al. Sturctural basis for potent inhibitory activity of the antibiotic
tigecycline during protein synthesis. PNAS. 2013;110(10):3812-3816.

9. Tygacil [package insert]. Philadelphia, PA: Wyeth Pharmaceuticals Inc; September 2013.













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FIGURE 1 STRUCTURES OF TETRACYCLINE, DOXYCYCLINE, MINOCYCLINE AND TIGECYCLINE
Tetracycline, the original member of the family, provides a four-ring backbone which interacts with
the 30S subunit of bacterial ribosomes. The rings are identified A-D beginning with the amide-
containing ring on the right side as A. Notice that tetracycline contains a methyl and hydroxyl group
attached to the C-ring. Doxycycline moves the hydroxyl group from the C-ring to the B-ring, as a
second-generation tetracycline. Minocycline, also a second-generation tetracycline, removes the
methyl and hydroxyl from the C-ring and includes a second dimethylamin in the C-7 position of the D-
ring. Tigecycline, a third-generation tetracycline or glycycline, builds on the minocycline backbone
and includes the tert-butyl-glycylamido group to the C-9 position of the D-ring. The long, bulky chain
in the 9
th
position produces the anti-resistance properties of tigecycline.
(Taken from Garrison M, Neumiller J, Setter S. Tigecycline: An investigational glycycline
antimicrobial with activity against resistant gram-positive organisms. Clin Thera. 2005;27(1):12-22.)
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FIGURE 2 CURE RATE COMPARISON OF TIGECYCLINE MONOTHERAPY WITH VANCOMYCIN/AZTREONAM
COMBINATION THERAPY. Tigecycline is a potent, broad-spectrum antibiotic affecting gram-negative and
gram-positive bacteria. This chart compares administration of tigecycline alone with the administration of
combination therapy of vancomycin and azetreonam. For each of the shown species, tigecycline produced the
similar or improved cure rates.
(Taken from Peterson L. A review of tigecycline - the first glycycline. International Journal of Antimicrobial
Agents. 2008;32(S4):S215-S222.)






















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FIGURE 3 CURE RATE COMPARISON OF TIGECYCLINE MONOTHERAPY WITH IMIPENEM-CILASTATIN
COMBINATION THERAPY. Tigecycline is FDA approved for complicated intra-abdominal infections. This
chart compares administration of tigecycline alone with the administration of combination therapy of
imipenem and cilastatin. For each infection, tigecycline produced the similar or improved cure rates.
(Taken from Peterson L. A review of tigecycline - the first glycycline. International Journal of Antimicrobial
Agents. 2008;32(S4):S215-S222.)