JP5061345B2 - Method for enhancing drug sensitivity of drug-resistant pathogenic microorganisms and method for preventing the appearance of highly drug-resistant bacteria - Google Patents

Description

  The present invention relates to a method for recovering and enhancing the drug sensitivity of a pathogenic microorganism having drug resistance by irradiating an LED (Light Emitting Diode) in the presence of the antibacterial substance, and a high concentration of the antibacterial substance The present invention relates to a method for preventing the appearance of pathogenic microorganisms having high drug resistance by irradiating LEDs in the presence. In particular, the present invention relates to a method for enhancing the susceptibility of bacteria such as cepacia, methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa and Serratia bacteria to antibiotics.

  In developed countries, antibiotics effective against many pathogenic microorganisms such as bacteria and viruses have been developed, and the wonder of infectious diseases is decreasing. However, if a specific drug is continuously administered to a specific pathogenic microorganism, the microorganism will eventually acquire resistance to the drug. In recent years, bacteria with drug resistance have emerged in this way, and opportunistic infections, fungal substitutions, and nosocomial infections due to the emergence of new multidrug-resistant bacteria have become problems to be overcome.

After the emergence of methicillin-resistant Staphylococcus aureus (MRSA), which has acquired resistance to heavy use of beta-lactams including cephem antibiotics, it became a social problem, and various countermeasures were studied. Antibiotics and antibacterials such as aminoglycoside antibiotics, glycopeptide antibiotics, macrolide antibiotics, chloramphenicol, phosphomycin and / or quinolone antibacterials as novel pharmaceutical compositions for MRSA infections Discloses a preparation containing a flavonoid (Patent Document 1). For the treatment and prevention of tuberculosis infection caused by multi-drug-resistant tuberculosis bacteria, the main component is lymphocytes collected from patients with drug-resistant protozoan infections that are proliferated and activated by interleukin 2 etc. (Patent document 2), and as an agent for controlling infection of livestock, poultry and fish and shellfish infected with drug-resistant bacteria such as vancomycin, lactic acid bacteria, especially Enterococcus faecalis (Enterococcus faecalis) ), Enterococcus faecium, or a dead cell thereof, or a drug containing the treated product as an active ingredient is disclosed (Patent Document 3). In addition, as a method of sterilizing MRSA-resistant bacteria by light irradiation, after spraying, spreading or wiping an aqueous solution containing pheophorbide sodium salt in a room, the room is irradiated with light having a wavelength of 600 to 700 nm. A disinfection method has been disclosed (Patent Document 4). Regarding a sterilization method using a photodiode, a method of generating a flash pulse from a blue light-emitting diode array and irradiating an object to be sterilized is disclosed, but the light source has a wavelength in the range of 419 to 519 nm with a peak at 466 nm. (Patent Document 5).
JP 2003-171274 A JP 2006-143709 A JP 2006-89421 A JP 2004-261595 A JP 2004-275335 A

  However, there has been no known method for irradiating a pathogenic microorganism having drug resistance with an LED to restore and enhance the drug sensitivity of the pathogenic microorganism. An object of the present invention is to alleviate serious nosocomial infection problems such as opportunistic infection of patients without immunity due to drug-resistant bacteria and infection from affected areas after surgery. The main problem is to provide a method for enhancing the sensitivity to the antibiotic and a method for preventing the appearance of pathogenic microorganisms having high drug resistance.

  The inventors of the present invention have found that when a pathogenic microorganism having drug resistance is irradiated with an LED in the presence of an antibiotic, the efficacy of the antibiotic is recovered and increased, and the present invention has been completed.

That is, the present invention provides the following (1) to ( 11 ).

(1) An antibacterial substance of a pathogenic microorganism having drug resistance by irradiating light having an intensity of 100 μW to 10 mW / cm 2 for 16 to 50 hours with an LED having a wavelength of 405 nm against the pathogenic microorganism having drug resistance. To increase susceptibility to.

(2) The method according to (1) above , wherein the LED is irradiated in the presence of an antibacterial substance.

( 3 ) The method according to (1) or (2), wherein the LED has a wavelength of 400 to 410 nm with a peak at 405 nm.

(4) Pathogenic microorganisms having drug resistance are Escherichia coli, Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Klebsiella pneumoniae, enterobacteria enterobacteria, Proteus, Salmonella typhi, Salmonella, Citrobacter, Shigella, Vibrio parahaemolyticus, pneumococci, Helicobacter pylori, archaea, cereus, serratia, pyogenes streptococci, acinetobacteria, influenza, cepacia, enterococci, staphylococcus epidermidis , Bacteria such as cataract, group B streptococcus, bacteroid, etc., or ringworm, superficial fungi, gypsum microspore, aspergillus, candida, cryptococcus, norcadia, mucor, and fungus Fungus, Q beta phage, M13 bacteriophage, influenza virus, hepatitis virus Scan, herpes virus (HSV), varicella zoster virus (VZV), AIDS virus: the sensitivity of any of the above-mentioned are those selected from the virus (Human Immunodeficiency Virus HIV), etc. (1) to (3) How to strengthen.

(5) Antibacterial substances include beta-lactam antibiotics, aminoglycoside antibiotics, macrolide antibiotics, tetracycline antibiotics, chloramphenicol antibiotics consisting of penicillins, cephems, carbapenems and monobactams From antibiotics, lincomycin antibiotics, polypeptide antibiotics, sulfa antibiotics, quinolone antibiotics, or detergents, disinfectants, bleaches, plant-derived antibacterial substances, or photocatalytic antibacterial substances The method for enhancing sensitivity according to any one of (1) to (4) , which is selected.

(6) of pathogenic microorganisms with drug resistance, in the presence of antimicrobial substances, susceptibility to the antibacterial substance according to any one of those selected from the following combinations (1) to (3) Sensitivity How to strengthen.
1) sensitivity of cepacia to erythromycin, gentamicin, chloramphenicol, tetracycline, or
2) sensitivity of MRSA to ampicillin, tetracycline, or
3) Susceptibility of Pseudomonas aeruginosa to chloramphenicol, tetracycline, or
4) Sensitivity of Serratia to erythromycin.

(7) Using an LED having a wavelength of 405 nm in the presence of a high-concentration antibacterial substance, irradiating light with an intensity of 100 μW to 10 mW / cm 2 for 16 to 50 hours , How to prevent.

( 8 ) The method for preventing the appearance of pathogenic microorganisms according to (7) above, wherein the LED has a wavelength of 400 to 410 nm having a peak at 405 nm.

( 9 ) The above (7) or (8), wherein a pathogenic microorganism having a high drug resistance is irradiated with light having an intensity of 2 to 10 mW / cm 2 for 16 to 50 hours using an LED having a wavelength of 405 nm. ) A method for preventing the appearance of the described pathogenic microorganisms.

(10) The method for preventing the appearance of the pathogenic microorganism according to any one of (7) to (9), wherein the pathogenic microorganism having high drug resistance is MRSA.

(11) The appearance of the pathogenic microorganism according to any one of (7) to (10) above, wherein the high-concentration antibacterial substance is selected from ofloxacin, cefazoline, cefotiam, cephamethazole, flomoxef, or imipenem. How to prevent.

  According to the present invention, since the susceptibility of pathogenic microorganisms having drug resistance is enhanced, it is possible to reduce the risk due to opportunistic infection and nosocomial infection after surgery. Furthermore, since treatment with a high concentration of antibacterial substance makes it possible to prevent the appearance of resistant bacteria by irradiating the LED in a situation where resistant bacteria are likely to appear.

  The present invention is a method for enhancing the sensitivity of a pathogenic microorganism having drug resistance to an antibacterial substance by irradiating an LED.

  Examples of the LED used in the present invention include a red diode, a green diode, a blue diode, a white diode, and an ultraviolet diode. A diode having a near-ultraviolet wavelength (350-410 nm) is effective, and a near-ultraviolet diode having a wavelength of 400-410 nm with a peak at 405 nm (hereinafter referred to as 405 nm LED) is most appropriate when considering the influence on the human body and the environment. It is.

  The light intensity applied to the LED resistant bacteria is preferably 100 μW to 100 mW / cm 2, and most preferably 2 to 10 mW / cm 2. The irradiation method to the irradiation object differs depending on the structure of the irradiation apparatus, the shape of the object, and the existing environment. When targeting animals, plants, and the like including humans, the measurement is performed in proximity (5 to 20 cm) or at an interval from the object to 200 cm.

  The drug sensitivity test is performed as follows. As shown in FIG. 1, the test bacteria are applied on a suitable solid medium, and a filter paper containing the drug to be tested is fixed thereon. After covering, the bacteria are grown at an appropriate culture temperature. At this time, a high concentration of the drug oozes out from the medium close to the filter paper for the drug, and the drug concentration decreases as the distance from the filter paper increases. A growth inhibition circle is formed at a drug concentration at which the test bacteria cannot grow. The degree of sensitivity (resistance) of the bacterium to be tested to the drug is measured by the radius of the growth inhibition circle. Moreover, when LED light is irradiated at this time, the drug sensitivity change by LED light can be compared and measured.

  “Sensitivity” in the present invention means that, for example, when a certain antibacterial substance B is effective against a bacterium A which is a pathogenic microorganism, the A bacterium is sensitive to the antibacterial substance B. “To enhance” means to enhance the effect of the antibacterial substance B against A bacteria.

  The “pathogenic microorganism having drug resistance” in the present invention refers to a pathogenic microorganism having resistance to a drug (antibacterial substance) and ineffective or less effective for the drug. Is included.

  Examples of the bacterium include Escherichia coli, Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonasella pneumoniae, Bacterial Enterobacteria (Proteus, Providencia, Morganella), Salmonella typhimurium, Salmonella enteritidis (Citrobacter), Citrobacter (Citrobacter) acter freundii), Shigella dysenteriae, Vibrio parahaelus mylyticus, Streptococcus pneumoniae, Helicobacter pylori (Helicobacter pylum) Serratia marcescens, Streptococcus pyogenes, Acinetobacter calcoaceticus, Haemophilus influenzae, Pseudomonia epacia), enterococci (Enterococcus), Staphylococcus epidermidis (Staphylococcus epidermidis), Moraxella catarrhalis (Moraxella (Branhamella) catarrhalis), B streptococci (Streptococcus agalactiae) and Bacteroides bacteria (Bacteroides fragilis) or the like can be mentioned.

  Examples of fungi include Trichophyton mentagrophytes, Superficial fungi (Epidermophyton floccusum), Microsporum gypsum, Aspergillus (c), Candida (c), Candida (c) Examples thereof include fungi, mucormycos, and scabs.

  As viruses, Q beta phage which is a phage virus that infects Escherichia coli, M13 bacteriophage, influenza virus, hepatitis virus, herpes virus (Herpes Simplex Virus: HSV), varicella zoster virus (VZV) And AIDS virus (Human Immunodefense Virus: HIV) and the like.

  The antibacterial substance used in the present invention refers to antibiotics, antifungal and antiviral agents, detergents, disinfectants, bleaching agents, plant-derived antibacterial substances, and antibacterial substances using photocatalysts. In particular, it refers to antibiotics, antifungals and antivirals to which pathogenic microorganisms such as bacteria, fungi and viruses are resistant.

  As antibiotics, beta-lactam antibiotics, penicillin antibiotics, oxacillin (MPIPC), benzylpenicillin (PCG) ampicillin (ABPC), piperacin (PIPC), amoxicillin, methicillin, etc. as cephem antibiotics, Cefazolin (CEZ), Cefotiam (CTM), Cefmetazole (CMZ), Flomoxef (FMOX), Cefoperazone (CPZ), Sulbactam Cefoperazone (SBT / CPZ), Cefotaxim (CTX), Cefazidime (CAZ), Cefopirome (CPR), (CFPM), cefozopran (CZOP), etc. as carbapenem antibiotics, imipenem (IPM), panipenem (PAPM), meropenem (MEPM), etc. as monobactam antibiotics Leonam (AZT), carmonam (CRMN), etc., and aminoglycoside antibiotics such as gentamicin (GM), tobramycin (TOB), amikacin (AMK), arbekacin (ABK), streptomycin, kanamycin, etc., macrolide antibiotics As the agent, erythromycin (EM), minocycline (MINO) as the tetracycline antibiotic, clindamycin (CLDM) as the lincomycin antibiotic, and chloramphenicol antibiotic can be mentioned. Furthermore, examples of the glycopeptide antibiotic include vancomycin (VCM) and teicoplanin (TEIC), and examples of the quinolone antibiotic include ofloxacin (OFLX), levofloxacin (LVFX), and sulfa antibiotics.

  Examples of antifungal agents include polyene macrolides such as amphotericin B, pyrimidine derivatives such as flucytosine, imidazoles such as miconazole, clotrimazole, and bifonazole, and triazoles such as fluconazole and itraconazole. be able to.

  Antiviral agents include zidovudine, stavudine, delavirdine, idoxuridine, acyclovir, famciclovir, ganciclovir, amantadine, rimantadine, etc., but viruses are the organisms most likely to undergo morphological variation among pathogenic microorganisms. Therefore, many drugs become resistant in a short period and lose their effect.

  By irradiating the LED, in the presence of the antibiotic, the enhancement of the sensitivity of the pathogenic microorganism having drug resistance to the antibiotic is found in the following combinations. That is, sensitivity to aminoglucoside antibiotics such as kanamycin and streptomycin of Escherichia coli, penicillin antibiotics such as ampicillin, chloramphenicol, tetracycline antibiotics, or penicillin antibiotics such as MRSA methicillin, ampicillin, cloxacin, oxacillin, etc. Susceptibility to Cephem antibiotics, cephem antibiotics, tetracycline antibiotics, Pseudomonas aeruginosa cambapenem antibiotics, tetracycline antibiotics, chloramphenicol, or Klebsiella pneumoniae ceftazidime, cefotaxime, etc. Sensitivity of enterobacteria enterobacteria to cephem antibiotics, Citrobacter susceptibility to cephem antibiotics, or Streptococcus penicillin Sensitivity to herbicides, Sericia penicillin antibiotics, cephem antibiotics, carbapenem antibiotics, erythromycin sensitivity, cepacia erythromycin, gentamicin sensitivity, or Streptococcus penicillin antibiotics, macrolide antibiotics Sensitivity to the agent.

  The present invention is also a method for preventing the appearance of pathogenic microorganisms having high drug resistance by irradiating LEDs in the presence of a high concentration of antibacterial substances. A pathogenic microorganism having a high drug resistance refers to a pathogenic microorganism having a strong drug resistance against an antibacterial substance used at a high concentration. Examples of pathogenic microorganisms having high drug resistance include MRSA, Pseudomonas aeruginosa, Sephacia and Serratia, and antibacterial substances to which pathogenic microorganisms are resistant include ofloxacin, cefazoline, cefotiam, cephamethazole, flomoxef. Or imipenem. Irradiation with an LED in the presence of the above antibacterial substance increases the susceptibility of pathogenic microorganisms having high drug resistance and can prevent their appearance, but a combination that exhibits a particularly remarkable effect is the MRSA ofloxacin. And can prevent the appearance of MRSA in the presence of ofloxacin.

Hereinafter, examples will be given to describe the present invention in more detail, but the present invention is not limited thereto.

1) Strain used The strains used in the test were methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa pA, sepa The Serratia marcescens was used.

2) Medium and equipment liquid medium: LB-Broth (Lennox) (nacalai tesque)
Solid medium: Mueller Hinton agar medium-N “Nissui” (manufactured by Nissui Pharmaceutical Co., Ltd.)
Drug sensitivity disk: SN disk, SN disk-K (manufactured by Nissui Pharmaceutical Co., Ltd.)
405 nm LED irradiation device: (manufactured by Koito Manufacturing)
Other equipment: Nissui Square Petri dish No. 2, sterile cotton swab (manufactured by Nissui Pharmaceutical Co., Ltd.)

3) Drug sensitivity disk SN disk and SN disk-K (Nissui Pharmaceutical Co., Ltd.) were used. Antibacterial substances include oxacillin (MPIPC), benzylpenicillin (PCG) ampicillin (ABPC), piperacin (PIPC), cefazolin (CEZ), cefotiam (CTM), cefmetazole (CMZ), flomoxef (FMOX), cefoperazone (CPZ) , Sulbactam cefoperazone (SBT / CPZ), cefotaxime (CTX), ceftazidime (CAZ), cefpirom (CPR), cefepime (CFPM), cefozopran (CZOP), imipenem (IPM), panipenem (PAPM), meropenem (PM) Aztreonam (AZT), Carmonam (CRMN), Gentamicin (GM), Tobramycin (TOB), Amikacin (AMK), Arbekacin (ABK), Minocycline (MINO) Erythromycin (EM), clindamycin (CLDM), vancomycin (VCM), teicoplanin (TEIC), ofloxacin (OFLX), was used levofloxacin (LVFX).

4) Cultivation method The used bacteria inoculated into LB-Broth is cultured with O / N, then inoculated again into new LB-Broth, and the bacterial solution in which the logarithmic growth period bacteria are adjusted to OD 600 nm = 0.05 with physiological saline is Mueller. The bacterial solution was thoroughly immersed in a sterilized cotton swab in a Nissui square dish No. 2 in which 80 ml of Hinton agar medium-N was hardened, and the excess bacterial solution was removed at the tube wall of the test tube, and the bacterial solution was applied as shown in FIG. A filter paper containing 8 kinds of drugs to be tested was fixed thereon. After covering, two identical petri dishes were prepared and divided into those that were irradiated with LED and those that were not irradiated, and cultured in an irradiation container for 24 hours.

5) LED irradiation experiment The petri dish including the LED irradiation device (one that irradiates the LED, one that does not irradiate the LED) was placed in a 32 liter (inner dimensions about 320 mm x 425 mm x 230 mm) plastic container for an irradiation experiment. (FIGS. 3 and 4) Irradiation was performed for 24 hours from a current of 10 mA with this irradiation apparatus and a distance of 130 mm with a 405 nm LED. The external temperature of the irradiation container was about 29 ° C., the surface irradiated with the 405 nm LED was about 34 ° C., and the temperature of the non-irradiated space of the 405 nm LED in the container was about 29 ° C. An angular petri dish that did not irradiate a 405 nm LED was placed in this space. The petri dish irradiated with the LED was covered with a Saran wrap with a gap of about 1 mm from the edge of the petri dish for the purpose of preventing the culture medium from drying.

6) Results Regarding drug sensitivity change by irradiation with LED light, FIG. 5 shows actual experimental results for Serratia, Sephacia and MRSA, and FIG. 6 shows Sephacia, MRSA, Pseudomonas and Serratia. The sensitivity evaluation for was shown.

1) Strain used Methicillin-resistant Staphylococcus aureus (MRSA) was used for the test.

2) Medium and equipment sensitive disc The same one as used in Example 1 was used.

3) Drug sensitivity disk SN disk and SN disk-K (Nissui Pharmaceutical Co., Ltd.) were used. Antibacterial substances include oxacillin (MPIPC), benzylpenicillin (PCG) ampicillin (ABPC), cefazolin (CEZ), cefotiam (CTM), cefmetazole (CMZ), flomoxef (FMOX), imipenem (IPM), gentamicin (GM) Arbekacin (ABK), Minocycline (MINO), Erythromycin (EM), Clindamycin (CLDM), Vancomycin (VCM), Teicoplanin (TEIC), Ofloxacin (OFLX) were used.

4) The culture method and the LED irradiation experiment were performed in the same manner as in Example 1.

5) Results As shown in FIG. 7, growth was achieved with cefazolin (CEZ), cefotiam (CTM), cefmetazole (CMZ), flomoxef (FMOX), imipenem (IPM), and ofloxacin (OFLX), to which MRSA is resistant at high concentrations. Due to the remarkable inhibitory effect, it became clear that the appearance of highly drug-resistant bacteria can be prevented by LED irradiation in the presence of antibacterial substances.

  By optimizing the pathogenic microorganisms of the present invention by irradiating the pathogenic microorganisms with LEDs to restore and enhance the drug susceptibility of the pathogenic microorganisms, opportunistic patients who have no immunity due to drug-resistant bacteria Serious hospital infection problems such as infection and infection from affected areas after surgery can be reduced. In particular, the ability to suppress the appearance of MRSA for drugs used at high concentrations is extremely useful to society.

It is drawing which shows the concept of a drug sensitivity experiment. It is drawing which shows the application | coating method of bacteria. It is the photograph replaced with drawing which shows the external appearance of irradiation experiment. It is the photograph replaced with drawing which shows the inside of an irradiation experiment tank. It is a photograph replaced with drawing which shows the result which shows the chemical | medical agent sensitivity change by irradiation of LED. It is drawing which shows chemical | medical agent sensitivity evaluation by irradiation of LED. It is the photograph replaced with drawing which shows the suppression result of appearance with respect to high concentration drug-resistant bacteria. It is a photograph replacing a drawing showing the result of growth inhibition (enlarged view) by ofloxacin.

Claims (11)

  Using an LED having a wavelength of 405 nm to a pathogenic microorganism having drug resistance, irradiating light having an intensity of 100 μW to 10 mW / cm 2 for 16 to 50 hours, thereby sensitizing the pathogenic microorganism having drug resistance to an antibacterial substance. How to strengthen.   The method for enhancing sensitivity according to claim 1, wherein the LED is irradiated in the presence of an antibacterial substance.   The method for enhancing sensitivity according to claim 1 or 2, wherein the LED has a wavelength of 400-410 nm peaking at 405 nm. Pathogenic microorganisms having drug resistance are Escherichia coli, Staphylococcus aureus, Methicillin-resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterobacteria enterobacteria, Proteus, Salmonella typhi, Salmonella, Citrobacter , Shigella, Vibrio parahaemolyticus, pneumococci, Helicobacter pylori, archaea, Bacillus cereus, Serratia, Streptococcus pyogenes, Acinetobacteria, Haemophilus influenzae, Sephacia, Enterococcus, Staphylococcus epidermidis, Cataract Bacteria such as group B streptococci and bacteroid bacteria, or fungi such as ringworm, superficial fungi, gypsum microspore, aspergillus, candida, cryptococcus, norcadia, mucor, and scarf, Q beta phage, M13 bacteriophage, influenza virus, hepatitis virus, Rupesuuirusu (HSV), varicella zoster virus (VZV), AIDS virus: a method for enhancing the sensitivity of any one of claims 1 to 3 are those selected from the virus (Human Immunodeficiency Virus HIV) and the like . Antibacterial substances include penicillin, cephem, carbapenem, and monobactam beta-lactam antibiotics, aminoglycoside antibiotics, macrolide antibiotics, tetracycline antibiotics, chloramphenicol antibiotics, linco Antibiotics such as mycin antibiotics, polypeptide antibiotics, sulfa antibiotics, quinolone antibiotics, detergents, disinfectants, bleaches, plant-derived antibacterial substances, or photocatalytic antibacterial substances The method for enhancing sensitivity according to any one of claims 1 to 4. The method for enhancing sensitivity according to any one of claims 1 to 3, wherein the susceptibility of the pathogenic microorganism having drug resistance to the antibacterial substance in the presence of the antibacterial substance is selected from the following combinations: .
1) sensitivity of cepacia to erythromycin, gentamicin, chloramphenicol, tetracycline, or
2) sensitivity of MRSA to ampicillin, tetracycline, or
3) Susceptibility of Pseudomonas aeruginosa to chloramphenicol, tetracycline, or
4) Sensitivity of Serratia to erythromycin. A method for preventing the appearance of pathogenic microorganisms having high drug resistance by irradiating light having an intensity of 100 μW to 10 mW / cm 2 for 16 to 50 hours using an LED having a wavelength of 405 nm in the presence of a high concentration of an antibacterial substance .   The method for preventing the appearance of pathogenic microorganisms according to claim 7, wherein the LED has a wavelength of 400 to 410 nm having a peak at 405 nm.   9. The pathogenic microorganism according to claim 7 or 8, wherein the pathogenic microorganism having a high drug resistance is irradiated with light having an intensity of 2 to 10 mW / cm 2 for 16 to 50 hours using an LED having a wavelength of 405 nm. To prevent the emergence of. The method for preventing the appearance of a pathogenic microorganism according to any one of claims 7 to 9, wherein the pathogenic microorganism having high drug resistance is MRSA. The method for preventing the appearance of pathogenic microorganisms according to any one of claims 7 to 10 , wherein the high-concentration antibacterial substance is selected from ofloxacin, cefazolin, cefotiam, cephamethazole, flomoxef, or imipenem.

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