Introduction
The discovery of antibiotics had a huge impact on humanity, saving countless lives from bacterial infections. However, overuse and misuse have led to the development of bacterial resistance to drugs, resulting in increased fatalities. The rise of drug-resistant bacteria has posed a significant challenge in treating bacterial infections, highlighting the need for the development of new antibiotics that do not promote bacterial resistance.
The use of metals in medicine dates back many centuries. Although essential metals can be toxic to cells in high concentrations, non-essential metals like silver (Ag), mercury (Hg), gold (Au), titanium (Ti), and tellurium (Te) are highly toxic to most bacteria and possess potent microbicidal properties even at very low concentrations.[
1,
2,
3] Over the past two hundred years, medical practitioners have employed oxides of Te, Mg, and As, as well as salts of Cu and Hg, to treat various diseases such as leprosy, tuberculosis, gonorrhea, and syphilis.[
2] The practice of using metals in medicine was common until Nobel laureate Sir Alexander Fleming discovered antibiotics in the 1920s, which led to a rapid decline in these applications. However, with the increasing prevalence of bacterial resistance to existing antibiotics, there is a critical need to develop novel, non-toxic antibiotics that do not contribute to resistance against other antibiotics. Consequently, metallodrugs have gained attention for combating drug-resistant bacteria. Among these, gallium [Ga(III)], a semi-metallic element, is utilized in various applications and devices, including electronics, semiconductors, and medical imaging. Ga(III) has shown therapeutic effects in the treatment of various disorders, including cancer, hemostasis, bone-related diseases, and autoimmune diseases.[
4] Gallium nitrate (Ga(NO
3)
3) in citrate buffer was approved by the Food and Drug Administration (FDA) for the treatment of hypercalcemia secondary to malignancy in 2003.
Remarkably, Ga(III) also exhibits broad-spectrum antimicrobial activity against many pathogens. Gallium shares several chemical and physical properties similar to iron, such as ionization potential, atomic radius, and electron configuration. In octahedral coordination geometry, the ionic radius of Ga
3+ is 0.62Å, while that of Fe
3+ (high spin) is 0.645Å.[
5] The tetrahedral ionic radius of Ga
3+ and Fe
3+ are 0.47 Å and 0.49 Å, respectively.[
6] These properties enable Ga(III) to mimic Fe(III), allowing it to bind to the binding sites on proteins where Fe(III) binds. However, unlike iron, Ga(III) does not undergo redox recycling, whereas Fe(III) is readily reduced to Fe(II) under physiological conditions. Ga(III) has shown antimicrobial activity against various bacterial pathogens because microorganisms cannot distinguish between the two metals. Enzymes substituted with Ga(III) cannot perform essential functions necessary for bacterial survival, resulting in the disruption of iron-dependent metabolic processes, including iron acquisition/utilization, electron transport, oxidative stress defense, and DNA synthesis.[
6]
Other antimicrobial metals, such as Ag and Cu, exhibit antimicrobial activity by reacting with reactive functional groups or by generating reactive oxygen species (ROS) from reactions with water and air. These mechanisms have led to the development of bacterial resistance through an efflux pump, conversion of the toxic metal to a less toxic form by modification, or sequestration by a metal-binding protein or ligands.[
2] In contrast, Ga(III) exerts its antimicrobial activity by mimicking Fe(III), an essential element for bacterial survival. This mechanism likely makes it much more difficult for bacteria to develop resistance to gallium, as reducing Ga(III) uptake would lead to the reduction of iron uptake, which is vital for bacterial growth.[
7,
8]
Due to multi-targeting antimicrobial activity against bacteria, including drug-resistant strains, Ga(III) has garnered significant attention as a novel antibacterial strategy. Consequently, Ga(III)-based compounds, including combination therapy using different forms of Ga(III), have been developed in a variety of ways to increase therapeutic efficacy and improve their low bioavailability. Ga(III) is hydrolyzed into various hydroxide species, such as insoluble Ga(OH)
3 and soluble Ga(OH)
4, under physiological conditions.[
9] The formation of Ga(III) complexes is one way to improve solubility and protect Ga(III) from hydrolysis, thereby increasing its bioavailability. For example, gallium nitrate (Ganite
TM), which is no longer available for clinical use in the US for reasons other than safety or effectiveness, needs to be administrated intravenously due to hydrolysis.[
10]
The usefulness of an antibiotic is increased if it has good solubility and bioavailability when administered orally. To increase gallium’s oral bioavailability, gallium-based compounds have been prepared by complexing Ga(III) ions with various ligands.[
11] Gallium maltolate (GaM), composed of three maltolate ligands bidentately bound to a gallium ion, exhibits some activity as both an anticancer and antimicrobial agent following oral administration.[
12] Researchers continue to explore its therapeutic applications, and GaM is still under investigation for the treatment of relapsed and refractory glioblastoma. Another oral gallium complex, tris(8-quinolinolato)gallium(III) (KP46), was synthesized for anticancer therapy and showed high hydrolytic stability.[
12,
13,
14] Although KP46 exerted promising activity against renal cancer and melanoma cells,[
15] it has poor bioavailability, possibly due to its low water solubility.[
13] Duffin et al. also synthesized alkyl gallium quinolinolate complexes, which exhibited good activity against the motile promastigote form of
Leishmania major with micromolar ranges of IC
50.[
16]
These gallium complexes demonstrate increased stability, solubility, and bioavailability, effectively delivering the antimicrobial agent Ga(III) to target sites and enhancing its therapeutic potential. These complexes also reduce potential side effects associated with free Ga(III) ions. To further improve the efficacy and safety of Ga(III)-based antimicrobial therapies, researchers are investigating various ligands for Ga(III) complexation. They are also developing innovative delivery systems, such as nanomaterials, gallium alloys, and liquid metals for controlled release and targeted delivery of Ga(III).[
7,
17,
18]
This review summarizes the mechanisms of action of Ga(III) to offer insights into enhancing the antibacterial activity of Ga(III)-based compounds. Understanding the mechanisms underlying gallium’s biological activities will enhance its therapeutic therapies for the treatment of infectious diseases.