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Betalactam Abiot
Betalactam Abiot
Betalactam Abiot
Cephalosporin Carbapenem
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Peptidoglycan
HOW??? layer
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Natural Penicillin
Aminopenicillin
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First noticed by Ernest Duchene, 1896
Rediscovered by Alexander Fleming
(founder of the name), 1929
Further intensive research and
production
Dr. Howard Florey, 1939
Andrew J. Moyer with mass production
patent, 1948
Natural Penicillin Alexander Fleming
Source: ?????? receiving Nobel Prize, 1945
Penicillin G, Penicillin VK, Benzathine
Penicillin, Procaine Penicillin
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General mechanisms of resistant
Inactivation of antibiotic by beta-lactamase (most common)
▪ Staphylococcus aureus, Haemophillus species, E. coli
▪ Pseudomonas aeruginosa, Enterobacter species
Modification of target PBP
Impaired penetration of drug to target PBPs
The presence of an efflux pump
Pharmacokinetics (PK)
Po:
▪ vary among Penicilin depend on acid stability and protein binding
▪ Methicillin: acid –labile ---- not for Po
▪ Dicloxacillin, Ampicillin, Amoxicillin: acid-stable, well absorbed,
impaired by food (except Amoxicillin)
Pe:
▪ Absorption is complete and rapid
▪ Preferable by iv than im, due to local pain
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Widely distributed in body fluids ([within cell] <
[intracellular fluids]) and tissues
Poor penetration into eye, prostate, central nervous
system (CNS)
Excretion:
▪ Mostly: in urine, also sputum, milk
▪ Nafcillin: biliary tr
▪ Oxacillin, Dicloxacillin, Cloxacillin: kidney and biliary
Clinical uses
Most widely effective and extensively used antibiotic
Avoid meal time when taking drugs (except
Amoxicillin)
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Penicillin V
Potassium salt phenoxymethyl penicillin
Oral: well absorbed
T max: 60 mnt
Indication:
▪ Mild gr + infection in throat, resp tr, soft tissue
▪ Doc. for Gr A Streptococcal pharyngitis
▪ Useful in oral cavity inf. due to anaerobic bacteria
Penicillin G
Not well absorbed po
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Penicillin G
Major limitation:
▪ Instable in acidic pH
▪ Susceptible to beta-lactamase (Penicillinase)
▪ Inactive against gram - bacilli
Pe: im, iv
DoC: Gram +, -, spirochaeta (ex: T. pallidum, N.
meningitidis, Group A streptococcus and Actinomycosis)
Long acting forms:
▪ Procaine PenG (12 hrs)
▪ Benzathine Pen (5 days)
Clinical use:
▪ Pneumonia, Meningitis, Endocarditis, Syphilis, Pharyngitis
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Pharmacokinetic (PK):
▪ Sensitive to gastric acid (pH<2)
▪ T1/2: 0.5 hr
▪ Distribution: wide, except CSF (Cerebro Spinal Fluid)
▪ Excression: renal
▪ Inhibited by Probenecid, Fenilbutazon, Sulfinpirazon, Acetozal,
Indometacine to increase blood level
Pharmacodynamics (PD):
▪ Time dependent
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Increase resistance of staphylococci to natural penicillins
Active againts Streptococcous and Staphylococcus
producing penicillinase
Not active:
Methicillin-resistant S. aureus
Gram negative
Best oral absorption (1 or 2 hrs before meals)
Cloxacillin
Dicloxacillin
Poor absorption
Nafcillin
Oxacillin
Indication: Skin and soft tissue infection
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First penicillin active against gram negative rods (E. coli and H.
influenzae)
Ampicillin: PO, IV, Amoxicillin: PO
Spectrum almost similar
Amox than Ampi
Absorption is better than ampicillin
Serum 2x serum ampicillin level
Smaller amount remain in intestinal tract
Less diarrhea
Less effective for shigella enteritis
Indication:
Mild infections (Otitis media, sinusitis, bronchitis, uti, bacterial diarrhea)
Less effective in H. influenzae and E. coli
Dental prophylaxis: amox 1 gr po
ADR:
Stomachache: for ampicillin
Allergic reaction to penicillin
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Adverse Reaction
In general: non toxic
Cross-sensitizing (duration and total dose)
Hypersensitivity: mild to severe allergic reaction:
▪ Serum sickness: Skin rash, urticaria, fever, joint swelling,
angioneurotic edeme, intense pruritus
▪ Oral lessions, interstitial nephritis, eosinophilia,
hemolytic anemia
▪ GI upset (nausea, vomiting, diarrhea)
▪ Anaphylactic shock
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Oral combination: only amoxicillin-clavulanate
Coverage:
Beta lactamase producing strain (S. aureus, H. influenza, N.
gonorrhoeae, E. coli, M. catarrhalis, Proteus, Klebsiella, Bacteroiddes
spp), anaerobic bact.
Less activity: Psudomonas, methicillin resistant S. aureus
Doc
Otitis media, sinusitis, bronchitis, uti, skin and soft tissue infections
Animal and human bites (anaerobic inf)
SE
GI distress
Diarrhea
Rashes
Candida superinfection
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Po: Carbenicllin
Absorption: excellent
Metabolism: too rapid, serum level low
Limited clinical usage
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Class Drug Antimicrobial spectrum
Natural penicillin Penicillin V Streptococcus species and oral cavity
anaerobes
Penicillinase-resistant penicillin Cloxacillin (Tegopen) Methicillin-sensitive Staphylococcus
Dicloxacillin (Dynapen) aureus and Streptococcus species
Nafcillin (Unipen)*
Oxacillin (Prostaphlin)*
Aminopenicillin Amoxicillin Same coverage as penicillin V, plus
Ampicillin Listeria monocytogenes,
Bacampicillin (Spectrobid) Enterococcus species, Proteus
mirabilis and some strains of
Escherichia coli
Beta-lactam–beta-lactamase Amoxicillin-clavulanate (Augmentin) Same coverage as aminopenicillins,
inhibitor combination plus betalactamase–producing
strains of methicillin-sensitive S.
aureus, Haemophilus influenzae and
Moraxella (formerly Branhamella)
catarrhalis
Antipseudomonal penicillin Carbenicillin (Geocillin) Limited activity against
Pseudomonas and Klebsiella species
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Misused and overused antibiotic
Penicillin-resistant organism---90% of
staphylococcal strains are beta-lactamase
producers
Broad spectrum penicillin also eradicate
normal flora ---- superinfection with
opportunistic and drug resistant species
(proteus, pseudomonas, enterobacter,
serratia, staphylococci, yeast, etc)
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Based on spectrum of antimicrobial activity
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Similar to Penicillins
gr +, gr -
Broader coverage: Methicillin sensitive S. aures. E. coli, P.
mirabilis, Klebsiella spp
Poor: P. aeruginosa, indole+ proteus, enterococcus spp, Serratia
marcescens, H. influenzae, gr- producing beta lactamase
PK:
Oral: Cephalexin, cephradine, cefadroxil
▪ Absorption in GI tr: good (not influenced by food)
▪ Excretion: Urine (high concentration--- !!! In severe renal failure)
▪ Impaired renal function: reduce dose
▪ Probenecid (tubular blocking agent): increase serum level of drugs
Pe:
▪ The only 1st gen. given Pe: cefazolin
▪ Excretion: kidney
▪ Be careful in impaired renal function
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Clinical use
Skin and soft tissue infection due streptococcus spp and methicillin
sensitive S. aureus
▪ Preferable to penicillinase-resistance penicilline due to lower GI se, better taste
UTI
▪ 2nd line drug after quinolone and TMP/SMX for UTI by gr – organisms
▪ Not active to Pseudomonas, Enterococcus spp
▪ Relative safe for pregnant woman
Pharyngitis with delayed type penicillin allergy
Generally: not effective againts H. influenza, M. catarrhalis, gr – beta
lactamase producing bacteria
Cefazolin:
▪ DOC for surgical prophylaxis
▪ For staphylococcal or streptococcal infections with history of mild penicillin
hypersensitivity
▪ Can’t cross Blood Brain Barrier (BBB) ----- not effective for meningitis
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Heterogenous group of drugs
Different in activity, pharmacokinetics, toxicity
Spectrum:
Better spectrum than 1st generation
▪ Againts beta-lactamase producing respiratory pathogens: H. influeanza, M. catarrhalis
▪ Plus gr –
Clinical usage:
▪ Otitis media, bronchitis, sinusitis --- consider TMP/SMX (cheaper)
▪ Second line of UTI
In general:
▪ Less active againts gr + than 1st gen.
▪ Not active againts enterocci or P. aeruginosa (~ 1st gen)
Cefamandole, cefuroxime, cefonicid, ceforanide, cefaclor:
▪ Active to: H. influenzae
▪ Not active: Serratia, B. fragilis
Cefoxitin, cefmetazole, cefotetan
▪ Active: B. fragilis
▪ Less active: H. influenzae
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PK:
Po: Cefaclor, cefuroxime axetil, cefprozil, loracarbef
Pe: Cefotetan, cefonicid, ceforanide, cefprozil
Dosage adjustments in renal failure
Clinical use:
▪ Oral 2nd gen:
▪ Active: beta-lactamse-producing H. influeanzae or B. catarrhalis
▪ Sinusitis, otitis, lower respiratory tract infection (LRI)
▪ Cefoxitin, cefotetan, cefmetazole
▪ Peritonitis or diverticulitis (anaerobic infection capacity advantage)
▪ Cefuroxime:
▪ Community-acquired pneumonia (CAP)
▪ Cross BBB but not effective for meningitis
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Spectrum
Extended gr – coverage (except cefoperazone)
Cross BBB
Ceftazidime, cefoperazone: P. aeruginosa
Loss efficacy to Strept. Pneumoniae, Staphylococcus spp
Not active against enterobacter species
Convenient dosing schedule, more expensive
Clinical use
To treat a wide variety of serious infections that are resistant to most
other drugs
▪ Ex: Ceftriaxone and cefixime for gonorrhea resistant to penicillin
Meningitis, sepsis
2nd line to otitis media, resp tr inf
Not effective for skin and soft tissue infections
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Better activity than 3rd gen.
More resistant to hydrolysis by chromosomal
beta-lactamase (ex. Produced by enterobacter)
Active: P. aeruginosa, enterobacteriaceae, S.
aureus, S. pneumonia, haemophillus,
neisseria
Excression: kidneys
Clinical role almost similar to 3rd gen. but
more active against most penicillin-resistant
strains of streptococci
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Allergy
Variety of hypersitivity:
▪ Anaphylaxis, fever, skin rashes, nephritis, granulocytopenia, hemolytic anemia
▪ Cross allergenicity between cephalosporin-penicillin is around 5-10%
▪ Be careful with history of anaphylaxis to penicillin
Toxicity
Local irritation with possible severe pain after i.m. injection
Thrombophlebitis after i.v. injection
Renal toxicity (interstitial nephritis, tubular necrosis) ---- withdrawal of
cephalosporin
Cefamandole, moxalactam, cefmetazole, cefotetan, cefoperazone:
hypoprothrombinemia and bleeding disorders
Superinfection
2nd and 3rd gen are ineffective against methicillin-resistant
staphylococci and enterococci --------- possible superinfection during
treatment
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What is the likely organism?
What is the major mode of resistance
Where is the infection
What is the local (ex. Hospital) environment?
What does the microbiology lab say?
How much does it cost?
Comorbid condition in the patient
Risk of side effect?
Availability of drug
Insurance support
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Class Drug Antimicrobial spectrum
First-generation cephalosporin Cefadroxil (Duricef) Improved coverage of methicillin-sensitive
Cephalexin (Keflex) S. aureus, E. coli, P. mirabilis and Klebsiella
Cephradine (Velosef) species
Second-generation cephalosporin Cefaclor (Ceclor, Ceclor CD) Compared with first-generation agents,
better coverage of beta-lactamase–
producing organisms such as methicillin-
Cefprozil (Cefzil) sensitive S. aureus, H. influenzae, M.
catarrhalis, E. coli, P. mirabilis and Klebsiella
species
Cefuroxime axetil (Ceftin)
Carbacephem Loracarbef (Lorabid) Same coverage as second-generation
cephalosporins
Third-generation cephalosporin Cefdinir (Omnicef) Variable loss of Staphylococcus and
Cefixime (Suprax) Pneumococcus coverage; compared with
Cefpodoxime (Vantin) second-generation cephalosporins,
Ceftibuten (Cedax) somewhat expanded coverage of gram-
negative organisms; enhanced coverage of
Proteus vulgaris and Providencia species
Animal and human bites Amoxicillin-clavulanate Depends on type of bite (e.g., cefuroxime axetil [Ceftin]
or doxycycline [Vibramycin] for cat bites)
Bacterial endocarditis prophylaxis Amoxicillin In patients with penicillin allergy: clindamycin (Cleocin),
cephalexin (Keflex), azithromycin (Zithromax),
clarithromycin (Biaxin)
Urinary tract infection Quinolone antibiotics, trimethoprim-sulfamethoxazole Amoxicillin, amoxicillin-clavulanate, cefuroxime axetil or
other cephalosporins, doxycycline, nitrofurantoin
(Furadantin) 28
Factors Cephalosporins Penicillin V*
Allergic reactions Fewer immediate and delayed Allergic reactions common
hypersensitivity reactions; must be
avoided in patients with a history of
immediate hypersensitivity to
penicillin
Patient tolerance Better taste, which increases More gastrointestinal side effects
compliance in children; fewer
gastrointestinal side effects
Cost More expensive Less expensive
Antimicrobial Broader antibacterial spectrum Narrower antibacterial spectrum;
spectrum less likely to induce antimicrobial
resistance; some penicillins cover
anaerobes, Listeria, Enterococcus
or Pseudomonas species
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Monobactams
Aztreonam
Relatively resistant to beta-lactamases
Active: gram-negative rods (pseudomonas, serratia)
Not active: gr + or anaerobes
Good for penicillin-allergic patients
Adv. Rx
▪ Skin rashes
▪ Elevation of serum aminotransferases
Beta-lactamase inhibitors
Calvulanic acid, Sulbactam, Tazobactam
Active: class A beta-lactamases (staphylococci, H. influenzae, N. gonorroeae,
salmonella, shigella, E. coli, K. pneumoniae)
Not good: class C beta-lactamases (enterobacter, citrobacter, serratia,
pseudomonas)
Available in fixed combination with specific penicillins
▪ Ampicillin-Sulbactam: beta-lactamase producing S. aureus, H. influenzae (except,
Serratia)
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Carbapenems
For infections by organisms resistant to other drugs
Imipenem:
▪ Wide spectrum: gr – rods, gr +, anaerobes
▪ Inactivated by dehydropeptidases in renal tubules
▪ Administered together with cilastatin (inhibitor of renal
dehydropeptidase)
▪ Adverse effect:
▪ Nausea, vomiting, diarrhea, skin rashes, reaction at infusion sites, seizures
Meropenem
▪ More active against gr – , but less active against gr+
▪ Not degraded by renal dehydropeptidases
▪ Adverse effect: less effect of seizures
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Vancomycin
Produced by Streptococcus orientalis
Active only against gr + bacteria (esp. staphylococci)
Mechanism:
▪ Inhibit transgycosylase, prevent elongation of peptidoglycan and weakend the cell wall ---
lysis of cell
Active against gr +
PK:
▪ Poorly absorbed from GI tr.
▪ PO: only for enterocolitis by Clostridium difficile, Pe (iv.) for severe infection
▪ Widely distributed in the body, CSS
▪ Excreted mainly by glomerular filtration
Indication:
▪ Pe: sepsis, endocarditis caused by methicillin-resistant staphylococci
▪ Vancomycin+Gentamycin: enterococcal endocarditis with penicillin allergy
▪ Vancomycin+cefotaxim/ceftriaxon/rifampin: meningitis by penicillin resistant strain of
pneumococcus
Adverse reaction:
▪ Minor reaction: phlebitis, chills, fever
▪ Administration with aminoglycoside: ototoxicity and nephrotoxicity
▪ Red man or red neck syndrome
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Teicoplanin
Very similar to vancomycin in mechanism of action and spectrum
Can be given im. Or iv.
Fosfomycin
Active: gr + and gr –
Available oral and pe.
Excretion via kidney
For treatment of uncomplicated lower urinary tract infection in
women
Bacitracin
Active: gr +
No cross-resistance between bacitracin-other antimicrobial drugs
Nephrotoxic
Only for topical use
Bacitracin+plymixin/neomycin: surface lessions of skin, wounds,
mucous membranes
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Cycloserine
Produced by Streptomyces orchidaceus
Inhibit gr+ and gr-
For tuberculosis by M. tuberculosis resistant to
first line drugs
Adverse reaction:
▪ Dose-related central nervous system toxicity
(headaches, tremors, acute psychosis, convulsions)
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Farmakologi dan Terapi (FKUI, 2007)
Basic and Clinical Pharmacology (The
McGraw-Hill, 2001)
James CW, Gurk-Turner. Cross-reactivity of
beta-lactam antibiotics. BUMC Proceedings
2001; 14:106-107
Goodman & Gilman’s. The Pharmacological
Basis of Therapeutics
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