Prospects for Clinical Introduction of Nitroimidazole Antibiotics for the Treatment of Tuberculosis

Nitroaromatic antibiotics have a long and controversial history in human and veterinary medicine. This controversy lies behind the presumption of many pharmaceutical companies that nitroaromatic compounds should be filtered from the list of drug-like compounds but stands at odds with the remarkably safe clinical record of use of such compounds. In this review, we will describe the whole-cell structure-activity relationships that have been reported for antimycobacterial nitroimidazoles as well as the available in vivo data supporting efficacy with a particular emphasis on nitroimidazo[2,1-b]oxazines such as PA-824. We will also explore the unique potential of such compounds to shorten the course of tuberculosis therapy by exerting a bactericidal effect on non-replicating bacilli. We will consider the mode of action of such compounds in sensitive organisms and discuss the mechanisms by which resistance may emerge. Finally, we will review the pharmacokinetics, toxicology and laboratory and animal studies linking nitroimidazoles with carcinogenicity and mutagenicity and assess the prospects for the clinical introduction of nitroimidazoles for the treatment of tuberculosis.