Mechanism of Action of Penicillin & Cephalosporin

Penicillins
Introduction
Penicillin belongs to the β-lactam family of antibiotics, which remain the most widely used
antibiotics in the world. Β-lactams are composed of five different groups of antibiotics, with the
β-lactam nucleus as the common feature: penicillins, cephalosporins, carbapenems, mono-
bactams, and carbacephems. Penicillins and cephalosporins are the most important with
carbapenems (imipenem, meropenem, and ertapenem), monobactams (aztreonam), and
carbacephems (loracarbef) reserved for serious infections such as nosocomial (hospital-acquired)
infections. β-lactams vary greatly from one another in their spectrum of antimicrobial activity,
ranging from an extremely narrow spectrum (e.g., β-lactamase–resistant penicillins) to a very
wide spectrum (e.g., imipenem and some cephalosporins).
Penicillin is a generic term for a group of antibiotics that share the β-lactam ring nucleus, similar
adverse drug reactions, and similar mechanism of action, but differ in their antibacterial
spectrum, pharmacokinetics, and resistance to β-lactamase enzymes.
Classification
Penicillin is a cyclic dipeptide consisting of two amino acids (d-valine, l-lysine), a particular
molecular configuration unknown in higher life forms. The synthesis in 1958 of the basic
structure of penicillins (6-aminopenicillanic acid) allowed for its manipulation by the addition of
various side chains to the β-lactam and thiazolidine rings (Fig. 33-4). Different salts (Na+, K+,
procaine, benzathine) were also created for pharmacokinetic purposes. On the basis of these
modifications, penicillins can be divided into four groups:
(1) Penicillin G and penicillin V,
(2) Anti staphylococcal penicillins that are resistant to β-lactamase produced by staphylococci,
(3) amino-penicillins with an extended-spectrum, and
(4) extended-spectrum penicillins with added activity against gram-negative organisms like
Pseudomonas aeruginosa.
Mechanism of action
Penicillin G is derived from various Penicillium molds. Discovery of the penicillin nucleus, 6-
aminopenicillanic acid, led to production of various semi synthetic penicillins. Those penicillins
have been synthesized in an attempt to improve the spectrum, activity and stability of the parent
compound. Many of the newer penicillins are modifications of ampicillin. For example,
substitution of a carboxyl group for the amino group of ampicillinon the acyl side chain
produced carbenicillin and ticarcillin. Bacteria differ from animal cells by possessing a rigid
outer layer, the cell wall. The bacterial cell possesses an unusually high internal osmotic
pressure. Injury to the cell wall or inhibition of its synthesis may result in cell lyses. The
peptidoglycan component of the cell wall is essential to the integrity of the bacterial envelope. It
consists of alternating units of N-acetylglucosamine and N-acetylmuramic acid, cross linked by
short strands of peptides. Almost all bacteria have cell membrane binding proteins called
penicillin-binding proteins (PBP). The PBPs are enzymes (transpeptidases, carboxypeptidases,
end peptidases) involved in the terminal stages of assembling the cell wall by cross linking the
peptidoglycan layer and reshaping the cell wall during growth and division. Binding of
transpeptidase PBPs causes inhibition of peptidoglycan synthesis. The final step in the action of
β-lactams probably involves inactivation of an inhibitor of autolytic enzymes in the cell wall.
Penicillins are structural analogs of D-alanyl-Dalanine and bind with high affinity to those PBPs
involved in cell wall synthesis. However, other PBPs act as β-lactamases and thus inactivate
penicillins and cephalosporins. Bacteria have 3–6 PBPs and different PBPs possess different
affinities for different drugs. The antibacterial activity of each β-lactam is dependent on its
ability to bind one of the PBPs that form or maintain cell wall structure while avoiding
destructive PBPs. PBPs are under chromosomal control and mutations can alter their number and
affinity for different β-lactam drugs. The antibacterial spectrum of any penicillin depends
primarily on its stability against bacterial β-lactamases but also its ability to reach the PBP on the
cell membrane and its binding affinity for the target PBP.
Differences in susceptibility of Gram-positive and Gram-negative bacteria to penicillins result
from structural differences in cell walls, differences in receptor sites (PBPs) and binding affinity
for the target PBP, the relative amount of peptidoglycan present (Gram positive bacteria possess
far more) and to the different types of β-lactamase produced by bacteria. In Gram negative
bacteria the outer portion of the cell wall is a lipopolysaccharide and lipoprotein bilayer
membrane, which may hinder the passage of drugs through the cell wall. All penicillins tend to
be ionized at physiological pH so will not diffuse through the lipid bilayer of the Gram-negative
outer membrane. The large hydrophobic groups on the narrow-spectrum penicillins (e.g.
penicillin G) hinder their passage through the porins in most Gram-negative outer membranes.
Substitution with more hydrophilic amino groups (e.g. ampicillin, amoxicillin) in place of the
benzyl group allows the molecule to penetrate this barrier and so broadens the spectrum of
activity. In contrast, Gram-positive organisms have a thin outer layer exterior to the
peptidoglycan layer, which β-lactams can rapidly penetrate.
Penicillins affect growing cells and have little influence on those that are dormant, so they should
not be administered with bacteriostatic agents. The antibacterial action of penicillin is greatest
during the periods of rapid bacterial multiplication. Penicillins (and cephalosporins) are time-
dependent killers; thus the time for which plasma concentrations remain above MIC is the best
predictor of treatment success and frequent dosing or depot formulations are therefore required.
Adverse effects
 Penicillins in general have a very wide therapeutic ratio as mammalian cells do not possess a
cell wall. Most toxic effects are related to hypersensitivity, usually immediate in onset. This
may manifest as local reactions at the site of injection (swelling, edema, pain) or systemic
reactions such as urticaria and skin rashes or anaphylaxis and collapse. Hypersensitivity
reactions have been recorded in most domestic species and can be fatal. They are much less
common after oral administration. If an animal is allergic to one form of penicillin it will
react to other forms.
 Penicillins can induce gastrointestinal super infection in many species in which fermentation
in the cecum is an important part of the digestive process. Thus penicillins should never be
given to guinea-pigs, ferrets, rabbits and hamsters by any route.
 Many of the acute reactions to penicillins reported in animals are in fact due to the toxic
effects of the potassium or procaine with which the penicillin has been combined. Potassium
penicillin G should be injected slowly. At high doses, procaine injected IM can cause
nervous excitement (ataxia, excitability, seizures), particularly in horses. The risk is greater if
there has been some dissociation of procaine from penicillin. Procaine benzyl penicillin
(procaine penicillin) should be stored in the refrigerator (high temperatures increase
 dissociation), should not be used past the expiry date and repeated use of the same injection
site should be avoided.

Cephalosporins
The isolation of the fungus Cephalosporium acremonium (now Acremonium chrysogenum) in
1948 by Brotzu from the harbor sewage of Sardinia and the subsequent isolation of the active
nucleus of cephalosporin C (7-amino-cephalosporinic acid) by Florey and Abraham at Oxford
University contributed in large measure to a golden age in antimicrobial chemotherapy. The
widespread use of cephalosporins because of their broad antibacterial spectra and low toxicity
and allergenicity has resulted in widespread microbial resistance to these agents.
Classification
Cephalosporins are most commonly classified according to their “generations”: first
generation (introduced in the 1960s), second generation (introduced in the 1970s), third
generation (introduced in the 1980s), fourth generation (cefepime introduced in 1997), and fifth
generation (advanced generation) (ceftaroline, introduced in 2010).

1st Generation

Drugs
Parenteral
Cefacetrile
Cephalothin
Cefapirin
Cefradine
Oral
Cefadroxil
Cefalexin
Cefradine
Spectrum
The antibacterial spectrum of the first-generation cephalosporins is similar for all drugs within
this group. Their only major advantages over aminopenicillins are their excellent activity against
penicillinase-producing Staphylococcus and generally greater activity against Pasteurella
• Good activity against Gram-positive bacteria including β-lactamase producing Staphylococcus
• Methicillin-resistant Staphylococcus are resistant
• Moderate activity against Gram-negative aerobes
• Resistant bacteria of clinical importance include Bordetella, Campylobacter, Pseudomonas
aeruginosa and Rhodococcus equi
• Acquired resistance common among Gram-negative bacteria, particularly Enterobacteriaceae,
but rare in Gram-positive bacteria
• Activity against obligate anaerobes unpredictable and less than for most penicillin.

2nd generation
Drugs
Cefaclor
Cefamandole
Cefotetan
Cefoxitin
Cefuroxime
Spectrum
Moderate Gram-positive and Gram-negative activity
• Moderately active against Gram-positive bacteria
• Broader activity against Gram-negative bacteria than first-generation cephalosporins but not
Pseudomonas aeruginosa
• Most of the group has only moderate activity against obligate anaerobes except cefoxitin which
has excellent activity

3rd generation
Drugs
Parenteral
Cefmenoxime
Cefotaxime cefquinome
Ceftiofur
Ceftizoxime
Ceftazidime
Ceftriaxone
Oral
Cefetamet
Cefixime
Cefpodoxime proxetil

4th Generation
Drugs
Cefepime
Cefpirome
Spectrum
Increased Gram-positive and Gram-negative activity
• High activity against Enterobacteriaceae
• Moderate activity against Pseudomonas aeruginosa
• Enhanced activity against Staphylococcus
• Enterococcus resistant
•Variable resistance amongst obligate anaerobes – Clostridium perfringens susceptible,
Bacteroides and Clostridium difficile resistant.

Mechanism of action
Cephalosporins were developed from cephalosporin C, a natural product of Cephalosporium
acreminium. Cephamycins are related drugs derived from Streptomyces spp or are synthetic
derivatives. These antibacterials are related structurally to benzylpenicillin and have a β-lactam
ring. Like penicillins, they inhibit cell wall synthesis by preventing cross-linking of
peptidoglycan.
However, unlike many types of penicillin, cephalosporins are resistant to β-lactamase produced
by Staphylococcus spp. By convention, cephalosporins discovered before 1975 were spelled with
a ‘ph’ and those discovered after 1975 with an ‘f’ but the recommended international
nonproprietary names have been changed now so that they are all spelled with an ‘f’.
Mechanisms of resistance
Resistance to cephalosporins can occur due to reduced permeability, enzymatic inactivation or
absence of specific PBPs. Constitutive and acquired resistance caused by periplasmic β-
lactamases against the different cephalosporins defines the different cephalosporin classes.
Extracellular expression of β-lactamases and efflux pumps has to some extent limited the use of
the newer cephalosporins in human medicine. Outbreaks of resistant nosocomial infections have
occurred in hospitals.
Some mutants have altered outer membrane permeability as well as drug pump efflux activity
and may show cross-resistance to aminoglycosides, chloramphenicol, fluoroquinolones,
tetracyclines and trimethoprim. Plasmid-mediated acquired resistance has also been described.