CN1030079A - 制备2-甲氧基甲基-青霉烯衍生物的方法 - Google Patents
制备2-甲氧基甲基-青霉烯衍生物的方法 Download PDFInfo
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- CN1030079A CN1030079A CN88103425A CN88103425A CN1030079A CN 1030079 A CN1030079 A CN 1030079A CN 88103425 A CN88103425 A CN 88103425A CN 88103425 A CN88103425 A CN 88103425A CN 1030079 A CN1030079 A CN 1030079A
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- 238000000034 method Methods 0.000 title claims abstract description 18
- CFGWXMNREXZXAY-SSDOTTSWSA-N (5R)-3-(methoxymethyl)-4-thia-1-azabicyclo[3.2.0]hept-2-en-7-one Chemical class COCC1=CN2[C@@H](CC2=O)S1 CFGWXMNREXZXAY-SSDOTTSWSA-N 0.000 title description 2
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- 239000001257 hydrogen Substances 0.000 claims abstract description 4
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- 125000006239 protecting group Chemical group 0.000 claims abstract description 4
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- 239000005864 Sulphur Chemical group 0.000 claims abstract 2
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- C07D499/88—Compounds with a double bond between positions 2 and 3 and a carbon atom having three bonds to hetero atoms with at the most one bond to halogen, e.g. an ester or nitrile radical, directly attached in position 2
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Abstract
本发明提供了制备式I旋光纯的(5R,6S,1'R)
青霉烯及其可作药用的盐为主要成分(>95%)的方
法;本发明的化合物具有抗菌活性;该方法的特征在
于使式(III)化合物环化(式III中,R2和P为保护基或
氢,Y为氧或硫,A为PPh3基团或氧)。
Description
本发明提供了一种制备如式(Ⅰ)所示的旋光纯的(5R,6S,1′R)构型的6-(1-羟乙基)-2-甲氧甲基-青霉烯-3-羧基衍生物及其可作药用的盐的方法,
其中R为酯化基或氢原子。
本发明还涉及制备还含有药学上适用的载体或稀释剂的药用组合物的方法,该组合物可以作为治疗人和哺乳动物感染的抗菌剂。
在本发明范围内,术语“旋光纯的”是指其可能的立体异构体混合物中至少含95%(5R,6S,1′R)构型的产物。术语“可作药用的盐”是指式(Ⅰ)化合物的羧基用有机或无机碱皂化形成的无毒的盐。还有术语“碱金属盐”和“碱土金属盐”,例如有:钠、钾、镁或钙盐,以及与氨或合适的有机胺形成的铵盐;有机胺有:低级烷基胺,例如三乙胺;羟基-低级烷基胺,例如2-羟基乙胺、双-(2-羟乙基)胺或三-(2-羟乙基)胺;羧酸的碱性脂肪族酯,例如4-氨基苯甲酸2-二乙氨基乙酯;低级亚烷基胺,例如1-乙基哌啶;环烷基胺,例如二环己胺;苄胺,例如N,N′-二苄基乙二胺、二苄胺或N-苄基-β-苯乙胺;或碱性氨基酸,例如精氨酸。式(Ⅰ)化合物特别好的可作药用的盐是钠盐、钾盐和精氨酸盐。
较好的前体药物酯是式(Ⅱ)表示的酯,
其中R是
a)酰氧甲基或1-(酰氧)乙基;
b)苯甲酰氧甲基或1-(苯甲酰氧)乙基,在环上未被取代或者被羟基、甲基化或乙酰化的羟基或者氨基取代;
c)烷氧羰氧甲基或1-(烷氧羰氧)乙基;
d)3-酞基;
e)在5位上未取代或取代有C1~C4烷基的2-氧代-1,3-二氧戊环-4-基;
f)在5位上未取代或取代有C1~C4烷基的(2-氧代-1,3-二氧杂环戊烯-4-基)甲基;
g)CH2CO2R′基,其中R′为C1~C4直链或带支链的烷基,或R′为苄基;
h)在4位未取代或取代有C1~C4烷基的2-氧代四氢呋喃-5-基。
上述a)中R定义中的术语“酰基”包括直链或带支链的C2~C10链烷酰基,或C4~C8环烷酰基。
式(Ⅰ)化合物最好的前体药物酯列于表1。
本发明方法的特征在于使式(Ⅲ)化合物环化,并且在需要时使生成的式(Ⅰ)化合物或其盐与式(Ⅴ)化合物反应,并且当P不是氢且R2不是R时,脱去P和R2保护基,并且如果需要,可以将生成的式(Ⅰ)化合物转变成它的盐,和/或将生成的式(Ⅰ)化合物的盐转变成游离的化合物,和/或将式(Ⅰ)化合物的巫涑刹煌难巍?
式Ⅲ中,P是氢,或者是羟基保护基;R2与上述式(Ⅱ)中定义的R相同,或者是羧基保护基;Y是氧或硫原子;A代表氧或PPh3基团,
式Ⅴ中,R的定义同上,X为氯、溴、碘、甲磺酰氧基、三氟甲磺酰氧基或甲苯磺酰氧基。羟基最好的保护基P是三甲基硅基、叔丁基二甲基硅基、四氢吡喃基、烯丙氧羰基或对-硝基苄氧羰基。当R2为羧基保护基(R2不是R)时,R2最好为烯丙基、对-硝基苄基或对-甲氧苄基。
脱去上述保护基的条件本身是已知的。式(Ⅲ)化合物的环化是在惰性有机溶剂(最好为苯、甲苯或二噁烷)中,通过简单的加热回流或于接近回流温度下进行的,或者是在惰性有机溶剂(例如氯仿、苯、甲苯、二甲苯或二噁烷)中,与三甲基亚磷酸酯或三乙基亚磷酸酯进行反应。
式(Ⅰ)化合物或其盐与式(Ⅴ)化合物的反应是在惰性有机溶剂(最好为二甲基甲酰胺、四氢呋喃、N-甲基吡咯烷酮或二甲基亚砜)中,于-10~+40℃(最好0~+25℃)下,在碱(例如碳酸氢钠、碳酸钾、三乙胺或吡啶)存在与否随意的情况下进行。
中间体式(Ⅲ)可以用下列氮杂环丁酮前体通过已知的方法制得:
其中P和R2的定义同上,L为离去基团(最好为乙酰氧基、苄氧基、苯磺酰基或氯)制备中间体式(Ⅲ)化合物的方法用反应式总结如下:
式(Ⅴ)、(Ⅵ)、(Ⅶ)、(Ⅷ)化合物是已知的,或者可以从已知化合物通过已知的方法制得。
式(Ⅰ)化合物及其可作药用的盐对革兰氏阳性和革兰氏阴性细菌具有显著的抗菌活性,并且当给人或哺乳动物服用时它们还具有良好的药物动力学的性质。由于以上特点以及它们的毒性非常低,在治疗上述细菌所引起的感染中,可以达到很高的治疗指数。
我们发现,6-(1′-羟乙基)-2-甲氧甲基-青霉烯-3-酸基衍生物的光学纯度[依据异构体混合物中(5R,6S,1′R)构型异构体的比例]在效果、抗菌谱和产物的化学酶催化稳定性方面起着重要的作用。因此,根据试验所用的菌株,与外消旋立体异构体的复杂混合物(在美国专利说明书4,272,437中公开的,按其中实例36所述方法制备的)相比,本发明式(Ⅰ)化合物的钠盐体外活性增加到8~30倍(表2)。此外,与先有技术叙述的混合物相比,按本申请所述方法制备的式(Ⅰ)纯的(5R,6S,1′R)构型化合物对于细菌的β-内酰胺酶和肾脏的脱氢肽酶显示出极好的稳定性,并且明显地改进了在整个pH范围内的化学稳定性。上述结果由体内试验确证(表3);确实,在革兰氏阳性和革兰氏阴性细菌引起的小白鼠试验感染的对照组和治疗组的比较中,式(Ⅰ)化合物的钠盐显示出极好的效果,在相同的试验条件下,先有技术的混合物未显示出在治疗上有用的抗菌活性。将二个产物进行分析和比较时我们发现,先有技术混合物含有微量(5R,6S,1′R)构型的差向立体异构体,很难用核磁共振谱(NMR)测定。该结果与同一作者公布的用相同路线制得的类似青霉烯的差向异构体混合物的结果是一致的(Y,Ueda,A.Martel,J.P.Daris.B.Belleau和M.Menard,Can.J.Chem.60.904,1982)。因此,先有技术产物的主要成分是5,6-顺式-1′R外消旋物,即为等分子量的对映体5R,6S,1′R和(5S,6S,1′S。
式Ⅱ化合物[为式(Ⅰ)化合物前体药物酯],在口服之后可以得到十分满意的生物利用度。与其它的前体药物青霉烯酯相比,例如与该类型的最新的化合物FCE22891(G.Franceschi等,J.Antibiotics 36,938,1983)相比,由于式Ⅱ化合物可以由胃肠道很好地吸收,同时在体内释放出的式(Ⅰ)化合物具有很好的药物动力学参数,因此在血浆中浓度较高和时间较长。如果将本发明的化合物1和20与FCE22101相应的前体药物酯,即FCE22891和FCE23761相比,由表4可见上述结果是显而易见的。
本发明还包括供人用或兽用的含有式(Ⅰ)化合物、其可作药用的盐及它们的前体药物酯的药用制剂。
为了口服,可以应用片剂或胶囊剂,片剂或胶囊剂含有前体药物酯(最好选自式(Ⅱ)化合物,选择表1所列化合物更好),以及稀释剂(例如乳糖、葡萄糖、蔗糖、甘露糖醇、山梨糖醇、纤维素和/或甘氨酸),润滑剂[例如二氧化硅、滑石、硬脂酸或其盐(如硬脂酸镁、硬脂酸钙)],和/或聚乙二醇;片剂还可以含有粘合剂[例如硅酸铝镁,淀粉(例如玉米、小麦、稻子或木薯粉),明胶,黄蓍胶,甲基纤维素,羧甲基纤维素钠],和/或聚乙烯吡烷酮,如果需要,可以含有崩解剂[例如淀粉、琼脂、藻酸或其盐(例如藻酸钠)],和/或泡腾混合物或吸附剂,着色剂,调味剂或甜味剂。
为了非胃肠道给药,可以应用输注溶液,最好为应用之前配制的等渗水溶液或混悬剂,例如可用冷冻干燥制品制得,输注溶液可以单独地含有式(Ⅰ)化合物或其可作药用的盐(最好选用钠、钾或精氨酸盐),或者与载体(例如甘露糖醇)并用。
上述制剂可以是灭菌的,和/或含有添加剂,例如防腐剂、稳定剂、湿润剂、和/或乳化剂、增溶剂、调节渗透压的盐和/或缓冲剂。
如果需要,本发明的药用制剂可以含有药学上有价值的其它物质,本发明的药用制剂可以按已知的方法(例如常用的混合,溶解或冷冻干燥)制得,本发明的制剂可以含有约0.1~100%,尤其是约1%~50%(在冷冻干燥的情况下,可以直到100%)的有效成分。
根据感染的细菌情况和感染的类型,治疗体重约为70公斤的温血动物(人或动物)每天所用的剂量为125毫克~约5克。
表2
旋光纯的式(Ⅰ)化合物(钠盐)和按美国专利说明书4,272,437中实例36制备的已知立体异构体混合物的体外抗菌活性 \\
体外最小抑制浓度(μg/ml)
微生物 5R,6S,1′R异构体 立体异构的混合物
金黄色葡萄球菌 Smith 0.09 0.78
金黄色葡萄球菌 39/2 Pen+0.09 6.25
金黄色葡萄球菌 2MR 3.12 >25
金黄色葡萄球菌 2101MR 3.12 >25
金黄色葡萄球菌 5635MR 0.19 3.12
表皮葡萄球菌 ATCC12228 0.09 1.56
酿脓链球菌 ATCC12384 0.022 0.39
唾液链球菌 ATCC9758 0.022 0.19
粪链球菌 ATCC6057 1.56 >25
粪链球菌 55 3.12 >25
屎链球菌 ATCC8043 3.12 >25
大肠埃希氏菌 K12 0.39 6.25
大肠埃希氏菌 R6K(T EM1) 0.39 12.5
大肠埃希氏菌 RPI(T EM2) 0.78 25
大肠埃希氏菌 P453(SHV-1) 0.39 6.25
大肠埃希氏菌 R997(H SM-1) 0.39 6.25
大肠埃希氏菌 RGN238(OXA-1) 0.78 12.5
大肠埃希氏菌 R46(OXA-2) 0.39 12.5
大肠埃希氏菌 R576(OXA-3) 0.39 6.25
大肠埃希氏菌 B 0.39 6.25
大肠埃希氏菌 B Cef.R 0.78 >25
伤寒沙门氏菌 ATCC14028 0.39 6.25
弗氏志贺氏菌 ATCC11836 0.19 1.56
产气克雷伯氏菌 1522E 0.39 3.12
产气克雷伯氏菌 1082E cef.R 0.39 6.25
阴沟肠杆菌 1321E 0.39 3.12
阴沟肠杆菌 P99 cef.R 0.39 6.25
产气肠杆菌 F46 0.78 12.5
产气肠杆菌 225 0.78 25
弗氏柠檬酸细菌 ATCC8090 0.39 3.12
弗氏柠檬酸细菌 4051 cef.R 6.25 >25
粘质沙雷氏菌ATCC2902 6.25 >25
乙酸钙不动杆菌 Bg3 1.56 >25
乙酸钙不动杆菌 N409 6.25 >25
奇异变形菌 FI7474 0.78 12.5
雷氏变形菌 ATCC925 1.56 >25
摩氏变形菌 ATCC25830 1.56 >25
普通变形菌 51 0.39 6.25
普罗威登斯菌属 stuartii Bs 60 3.12 >25
(接上页表2)
铜绿假单细胞菌 2598 >25 >25
铜绿假单细胞菌 ATCC 19660 >25 >25
表3
旋光纯的式(Ⅰ)化合物,其钠盐和它们典型的前体药物酯(化合物20)对小白鼠试验性感染的治疗效果
ED50感染
感染后治疗时间(mg/kg,累积剂量)
(小时) -
钠盐a)酯(化合物20)b)
金黄色葡萄球菌Smith 2 0.21 -
大肠埃希氏菌G 0.5-1.5-6 6.7 13.1
a)皮下注射
b)口服
表4
式(Ⅰ)化合物典型的前体药物酯与FCE22101相应的酯的药物动力学参数
化合物(1)
参数 对比 对比
化合物1 (FCE22891) 化合物20 (FCE23761)
静脉注射母体药物的 920 307 920 307
AUC(2)
(μg.min/ml)
口服前体药物的 763 151 745 85
AUC
口服生物利用度%(3)83 49 81 27
α 7
口服半存留期{ 7 6 9.5
(min) β 13
对比化合物:X=OCONH2
2)小白鼠20mg/kg
3)口服生物利用度%= ((AUC os)前体药物)/((AUC iv)药物) ×100
4)表4中“AUC”=血液中药物浓度-时间曲线下的面积(译注)
实例1
(5R,6S)-[1(R)叔丁基二甲基硅氧基-乙基]-2-甲氧甲基青霉烯-3-羧酸烯丙酯
将(3S,4R)-1-[1-(烯丙氧羰基)-1-(三苯基正膦亚基)甲基]-3-[1(R)叔丁基二甲基硅氧乙基]-4-(银硫代)-氮杂环丁-2-酮(727mg)溶于无水CH3CN(20ml)中,并与甲氧基乙酰氯(110μl)反应。于室温下搅拌10分钟后,反应混合物用乙酸乙酯稀释,通过硅藻土过滤,用5%碳酸氢钠水溶液洗涤,再用盐水洗涤二次。真空蒸发溶剂后,残余物溶于甲苯(150ml)中,并加热回流90分钟。
溶液经减压浓缩,然后进行层析(230-400目硅胶;以环己烷-乙酸乙酯80/20为洗脱剂),得标题化合物(360mg;87%),为淡黄色油状物。
红外(CHCl3)ν1785,1700cm-1
δ:0.09(6H,s)
0.89(9H,s)
1.26(3H,d,J=6.5Hz)
3.39(3H,s)
3.67(1H,dd,J=<和7Hz)
4.23(1H,m)
4.5-4.8(4H,m)
5.0-5.5(2H,m)
5.56(1H,d,J<2Hz)
5.55-6.05(1H,m)
实例2
(5R,6S)-6-[1(R)羟乙基]-2-甲氧基甲基青霉烯-3-羧酸烯丙酯
将(5R,6S)-6-[1(R)叔丁基二甲基硅氧乙基]-2-甲氧基甲基青霉烯-3-羧酸烯丙酯(360mg)在无水四氢呋喃(6ml)中的溶液在搅拌下依次用乙基(0.6ml)和氟化四丁铵三水合物(930mg)处理。
让溶液于室温下静置过夜,然后浓缩至小体积,经硅胶层析(以环己烷/乙酸乙酯1/1为洗脱剂)得标题化合物(250mg),为白色粉状物。
紫外(CHCl3)λ最大:326nm。
实例3
(5R,6S)-6-[1(R)羟乙基]-2-甲氧甲基青霉烯-3-羧酸烯丙酯
将(3S,4R)-1-[1-(烯丙氧羰基)-1-(三苯基正膦亚基)甲基]-3-[1(R)羟乙基]-4-(银硫代)-氮杂环丁-2-酮(6.1g)在无水乙腈(250ml)中的溶液于-10℃用甲氧基乙酰氯(1.2ml)处理,然后于0℃继续搅拌15分钟。加入乙酸乙酯,所得混合物通过硅藻土过滤。有机相用碳酸氢钠水溶液洗涤,经硫酸钠干燥并浓缩,残余物经快速层析(硅胶230-400目,以己烷-乙酸乙酯混合液为洗脱剂),得(3S,4R)-1-[1-(烯丙氧羰基)-1-(三苯基正膦亚基)甲基]-3-[1(R)羟乙基]-4-(甲氧基乙酰基硫代)-氮杂环丁-2-酮(4.2g),为淡黄色泡沫状物。
以上制得的产物溶于甲苯(250ml)中并回流2小时。经冷却和除去溶剂后残余物通过硅胶层析提纯(以环己烷-乙酸乙酯混合液为洗脱剂),得标题化合物(2.5g),为白色粉末。
红外(KBr)δ1775,1705cm-1
紫外(乙醇)λ最大:326nm
实例4
(5R,6S)-6-[1(R)-羟乙基]-2-甲氧甲基-青霉烯-3-羧酸钠盐
将((5R,6S)-6-[1(R)羟乙基]-2-甲氧甲基青霉烯-3-羧酸烯丙酯(2.5g)溶于无水四氢呋喃(60ml)中,该溶液依次加乙酸乙酯钠(1.05g),三苯基膦(300mg)和四(三苯基膦)钯(0)(100g)处理。继续搅拌30分钟,随后经薄层层析(TLC)检验,不再有起始原料。
向上述溶液中加入乙醚(40ml),通过离心分离沉淀,将粗制品溶于最小量的水中,经反相层析提纯(Lichroprep RP C-18 Merck),依次用水和水-丙酮为洗脱剂,收集含产品的部分并冷冻干燥,得标题化合物(1.8g),为白色粉末。
红外(KBr)ν 1755,1600,1575cm-1
紫外(H2O)λ最大:258nm(ε=4044);
λ最大:306nm(ε=6076)。
核磁共振(200MHz,D2O)
δ:1.30(3H,d,J=6.3Hz)
3.38(3H,s)
3.91(1H,dd,J=1.6和6.0Hz)
4.25(1H,m)
4.48和4.79(2H,二个二重峰,J=14.0Hz)
5.66(1H,d,J=1.6Hz)
实例5
(5R,6S)-6-[1(R)-羟乙基]-2-甲氧甲基-青霉烯-3-羧酸乙酰氧基甲酯
将(5R,6S)-6-[1(R)羟乙基]-2-甲氧甲基青霉烯-3-羧酸钠盐(258mg)在无水二甲基甲酰胺(DMF)(3ml)中的溶液于0℃用乙酰氧基甲基溴(145mg)处理,然后于室温搅拌2小时。
在乙酸乙酯和2%Na HCO3水溶液之间进行分配后,有机相用盐水洗涤二次,然后干燥和真空浓缩。向粗产品中加入异丙醚,经过滤和干燥得到白色沉淀(220mg)。
红外(KBr)ν3590,1780,1765,1715,1580cm-1
紫外(CHCl3)λ最大:327nm。
核磁共振(CDCl3,90MHz)
δ:1.33(3H,d,J=6.5Hz)
2.12(3H,s)
2.3(1H,bs,D2O交换)
3.39(3H,s)
3.71(1H,dd,J=<2和6.5Hz)
4.71(1H,m)
4.47和4.73(2H,二个二重峰,J=16Hz)
5.58(1H,d,J<2Hz)
5.82(2H,ABq的中心)。
实例6
(5R,6S)-6-[1(R)-羟乙基]-2-甲氧甲基-青霉烯-3-羧酸(5-甲基-2-氧代-1,3-二氧杂环戊烯-4-基)甲酯
将(5R,6S)-6-[1(R)-羟乙基]-2-甲氧甲基青霉烯-3-羧酸钠盐(258mg)在无水DM F(3ml)中的溶液用(5-甲基-2-氧代-1,3-二氧杂环戊烯-4-基)甲基溴(180mg)处理,并于室温下搅拌2小时。反应混合物注入乙酸乙酯/水中,有机相用水洗涤二次,然后干燥并真空浓缩。用异丙醚处理残余物,得白色结晶(240mg)。
紫外(CHCl3)λ最大:326nm
红外(KBr)ν3450,1820,1780,1725,1710cm-1
核磁共振(CDCl3,90MHz)
δ:1.32(3H,d,6.5Hz)
2.17(3H,s)
2.37(1H,bs,D2O交换)
3.38(3H,s)
3.69(1H,dd,J<2和6.5Hz)
4.20(1H,m)
4.43和4.70(2H,二个二重峰,J=16Hz)
4.93(2H,s)
5.60(1H,d,J<2Hz)
实例7
(5R,6S)-6-[1(R)-羟乙基]-2-甲氧甲基-青霉烯-3-羧酸(5-甲基-2-氧代-1,3-二氧杂环戊烯-4-基)甲酯
步骤A
在搅拌下于10℃向(3S,4R)-3-[1(R)三甲基硅氧乙基]-4-甲氧乙酰基硫代氮杂环丁-2-酮(3.3克)在无水甲苯(35ml)的溶液中加入三乙胺(1.8ml),随后再滴加草酰氯酸(5-甲基-2-氧代-1,3-二氧杂环戊烯-4-基)酯(2.7g)在甲苯(10ml)中的溶液。所得溶液于室温搅拌15分钟,然后依次用水、5%碳酸氢钠水溶液和水洗涤。有机溶液经Na2SO4干燥后,浓缩至20ml,加入三乙基亚磷酸酯(4ml),将溶液回流5小时。混合物冷却至室温,然后用水洗涤三次,经硫酸钠干燥,除去溶剂,残余物经硅胶层析(以正己烷-乙酸乙酯为洗脱剂),得(5R,6S)-6-[1(R)-三甲基甲硅烷氧乙基]-2-甲氧甲基-青霉烯-3-羧酸(5-甲基-2-氧代-1,3二氧杂环戊烯-4-基)甲酯(2.9g),为无色油状物。
步骤B
将上述产品溶于95%乙醇(160ml)中,向其中加入乙酸(2ml)。于室温搅拌1小时后,混合物经真空浓缩至干。加入异丙醚(50ml),经过滤和干燥,得白色结晶(2.0g)。
紫外(CHCl3)λ最大 326nm
红外(KBr)ν 3450,1820,1780,1725,1710,1580cm-1
Claims (4)
2、按照权利要求1所述的方法,其中青霉烯I为6-(1-羟乙基)-2-甲氧甲基-青霉烯-3-羧酸乙酰氧基甲酯。
3、按照权利要求1所述的方法,其中青霉烯I为6-(1-羟乙基)-2-甲氧基甲基-青霉烯-3-羧酸(2-氧代-1,3-二氧杂环戊烯-4-基)酯。
4、一种制备以权利要求1定义的化合物作为有效成分且含有药学上适用的载体或稀释剂的的药物组合物的方法。
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US5399679A (en) * | 1992-06-16 | 1995-03-21 | Farmitalia Carlo Erba S.R.L. | (1'R,3S,4R)4-acylthio azetidinones |
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US4272437A (en) * | 1978-12-18 | 1981-06-09 | Bristol-Myers Company | Antibacterial agents, and 4-thio azetidinone intermediates |
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US4482565A (en) * | 1980-02-22 | 1984-11-13 | Farmitalia Carlo Erba S.P.A. | β-Lactam-containing antibacterial agents and β-lactamase inhibitors |
US4558042A (en) * | 1981-05-06 | 1985-12-10 | Farmitalia Carlo Erba S.P.A. | β-Lactam-containing antibacterial agents and β-lactamase inhibitors |
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