Chapter 10 – Antimicrobial Drugs semisynthetic antimicrobial

 chemically altered antibiotics

drugs  more effective, longer lasting, or easier to
 chemicals that affect physiology in any administer than naturally occurring
manner antibiotics

chemotherapeutic drugs synthetic drugs

 drugs that act against diseases  antimicrobials that are completely
synthesized in a laboratory
antimicrobial agents
 antimicrobials
 drugs for treating infections

History of Antimicrobial Agents

Paul Ehrlich
 a German scientist
 proposed the term chemotherapy
 the use of chemicals that would
selectively kill pathogens while
having little or no effect on a patient
 he wrote of “magic bullets”
 arsenic compounds that killed
microbes
 bind to receptors on germs to bring
about their death while ignoring host
cells, which lacked the receptor
molecules

Alexander Fleming
 British bacteriologist
 reported the antibacterial action of
penicillin released from Penicillium mold,
which creates a zone where bacteria don’t
grow
Gerhard Domagk
 German chemist
 discovered sulfanilamide
 first practical antimicrobial agent
efficacious in treating a wide array of
bacterial infections
Selman Waksman
 discovered that other microorganisms are
sources of useful antimicrobials, most
notably species of soil-dwelling bacteria
in the genus Streptomyces
 coined the term antibiotics
 antimicrobial agents that are
produced naturally by an organism
 in common usage today, it denotes
to an antibacterial agent, including
synthetic and excluding agents
with antiviral and antifungal
activity
Mechanism of Antimicrobial Action
› The key to successful chemotherapy against
microbes is selective toxicity
 More toxic to a pathogen than to the
pathogen’s host
› Antibacterial drugs constitute largest
number and diversity of antimicrobial
agents
 There are many differences between
the structure and metabolism of
pathogenic bacteria and their
eukaryotic hosts
› Fewer antifungal, antiprotozoan, and
anthelminthic drugs are available
 Fungi, protozoa, and helminths are
eukaryotic chemoheterotrophs just like
their hosts
› The number of antiviral drugs is also limited,
despite major difference in structure,
because viruses utilize their host cells’
enzymes and ribosomes to metabolize and
replicate
 Drugs that are effective against viral
replication are likely toxic to the host
as well
Inhibition of Cell Wall Synthesis
Inhibition of Synthesis of Bacterial Cell Walls
› Most common antibacterial agents act by
preventing the cross-linkage of NAM
subunits
› Most prominent among these drugs are
beta-lactams
 Penicillins, cephalosporins, and
carbapenems
 Antimicrobials whose functional
portions are called beta-lactam rings
 Inhibit peptidoglycan formation by
irreversibly binding to the enzyme that
cross-link NAM subunits
 Semisynthetic derivatives, such as
methicillin and imipenem from the
natural penicillin G:
o More stable in the acidic
environment of the stomach
o More readily absorbed in the
intestinal tract
o Less susceptible to deactivation by
bacterial enzymes
o More active against more types of
bacteria
› Other antimicrobials, such as
lipoglycopeptides – for example,
vancomycin, oritavancin – and cycloserine, a
semisynthetic
 Directly interfere with particular
alanine-alanine bridges that link NAM
subunits in many Gram-positive
bacteria
 Bacteria that lack alanine-alanine
crossbridges are naturally resistant to
these drugs
› Bacitracin
 Blocks the transport of NAG and NAM
across the cytoplasmic membrane to the
wall
› Isoniazid (INH) and ethambutol
 Disrupt the formation of mycolic acid in
mycobacterial species
› Absence of correctly formed peptidoglycan
causes growing bacterial cells to have
weakened cell walls that are less resistant to
the effects of osmotic pressure
› Prevent bacteria from increasing the amount
of cell wall but have no effect on existing
peptidoglycan
› Effective only on growing cells; dormant
cells are unaffected
Inhibition of Synthesis of Fungal Walls
› Fungal cell walls are composed of various
polysaccharides containing a sugar – 1,3-d-
glucan – not found in mammalian cells
› Echinocandins inhibit the enzyme that
synthesizes glucan
› Without glucan, fungal cells cannot make cell
walls, leading to osmotic rupture
Inhibition of Protein Synthesis
Interference with Prokaryotic Ribosomes
› Antimicrobial agents take advantage of the
difference between ribosomes to selectively
target bacterial protein without significantly
affecting eukaryotes
 Prokaryotic ribosomes are 70S (30S
and 50S)
 Eukaryotic ribosomes are 80S (40S and
60S)
› Antimicrobials that target the 30S ribosomal
subunit
a. Aminoglycosides
 streptomycin and gentamicin
 change the shape of the 30S
subunit, making it impossible for
the ribosomes to read the codons
of mRNA correctly
b. Tetracyclines
 block the tRNA docking site (A
site), which then prevents the
incorporation of additional amino
acids into a growing polypeptide
› Antimicrobials that target the 50S ribosomal
subunit
a. Chloramphenicol
 Block the enzymatic site of the 50S
subunit, which prevents
translation
b. Lincosamides, streptogramins, and
macrolides
 Bind to a different portion of the
50S subunit, preventing movement
of the ribosome from one codon to
the next; as a result, translation is
frozen, and protein synthesis is
halted
› Antisense nucleic acids
 Fomivirsen is the first of this class of
drugs to be approved
o Inactivates cytomegalovirus and
is used to treat eye infections
 RNA or single-stranded DNA molecules
that are designed to be complementary
to specific mRNA molecules of
pathogens
 Block ribosomal subunits from
attaching to pathogenic mRNA with no
effect on human mRNA
› Oxazolidinones
 Stop protein synthesis by blocking
initiation of translation
 Used as last resort in treating
infections of Gram-positive bacteria
resistant to other antimicrobials

Interference with Charging of Transfer RNA
molecules
› At the base of each transfer RNA molecule
there is an anticodon composed pf three
nucleotides complementary to the
nucleotides of a codon that codes for a
specific amino acid
› Aminoacyl-tRNA synthetase – “charge” or
“load” amino acids onto tRNA molecules
› Mupirocin
 Selectively binds to isoleucyl-tRNA
synthetase, the enzyme that loads
isoleucine in Gram-positive bacteria
 Selectively toxic because it does not
bind to any eukaryotic tRNA molecules
 Gram-positive cells cannot load
isoleucine, so protein synthesis cannot
proceed past isoleucine codons
Disruption of Cytoplasmic Membranes
› Gramicidin
 Disrupt the cytoplasmic membrane of a
targeted cell, often by forming a channel
through the membrane, damaging its
integrity
› Polyenes
 Nystatin and amphotericin B
 Also disrupts the cytoplasmic
membrane of a targeted cell by forming
a channel through the cytoplasmic
membrane
 Antifungal and antiprotozoan drug
 attach to ergosterol – lipid constituent of
fungal membranes – disrupting the
membrane and causing lysis
 Humans are susceptible because they
contain cholesterol, which is similar to
ergosterol
 Bacteria lack sterol; not susceptible
› Azoles (fluconazole) and allylamines
(terbinafine)
 Antifungal and antiprotozoan drug
 Disrupt cytoplasmic membranes by
inhibiting the synthesis of ergosterol
 Harmless to humans because human
cells do not manufacture ergosterol
 Bacteria lack sterol; not susceptible
› Polymyxin
 Produced by Bacillus polymyxa
 Effective against Gram-negative bacteria
 Toxic to human kidneys, thus usually
reserved for use against external
pathogens that are resistant to other
antibacterial drugs
› Pyrazinamide
 Disrupts transport across the
cytoplasmic membrane of
Mycobacterium tuberculosis
 Most effective against intracellular,
nonreplicating bacterial cells
› Praziquantel and ivermectin
 Antiparasitic drugs
 Change the permeability of cell
membranes of several types of
parasitic worms
Inhibition of Metabolic Pathways
› Living things share certain metabolic
reactions, other chemical reactions are
unique to certain organisms
› Antimetabolic agents are effective if there is
difference between the metabolic processes
of a pathogen and its host
› Kinds of antimetabolic agents:
a. Atovaquone, which interferes with
electron transport in protozoa and
fungi
b. Heavy metals, which inactivate
enzymes
c. Agents that disrupt tubulin
polymerization and glucose uptake by
many protozoa and parasitic worms
d. Drugs that block the activation of
viruses
e. Metabolic antagonists
o Sulfanilamide
 Collectively called sulfonamides
or sulfa drugs
 Structural analogs of para-
aminobenzoic acid (PABA) –
crucial in the synthesis of
nucleotides required for DNA
and RNA synthesis
 Compete with PABA molecules
for the active site of the
enzyme involved in the
production of dihydrofolic acid
which leads to a decrease in the
production of THF and thus of
DNA and RNA
 Human metabolism is
unaffected
o Trimethoprim
 Binds to the enzyme involved
in the conversion of
dihydrofolic acid to THF
› Some antiviral agents target the unique
aspects of the metabolism of viruses
a. Amantadine, rimantadine, and weak
organic bases
 Neutralize the acid of
phagolysosomes and thereby
prevent viral uncoating
 Amantadine is no longer effective
against influenza type A virus
b. Protease inhibitors interfere with the
action of protease – and enzyme that
 HIV needs near the end of its
replication
Inhibition of Nucleic Acid Synthesis
› Several drugs function by blocking either
the replication of DNA or its transcription
to RNA
› Because only slight differences exist
between the DNA of prokaryotes and
eukaryotes, drugs that affect DNA
replication often act against both types of
cells
› Actinomycin
 Binds to DNA and effectively blocks
DNA synthesis and RNA transcription
not only in bacterial pathogens but in
their hosts as well
 Generally, not used to treat infections,
but are used in research of DNA
replication and may be used carefully to
slow replication of cancer cell
› Quinolones
 Fluoroquinolones – contain fluorine
 Inhibit DNA gyrase, the bacterial
enzyme necessary for correct coiling
and uncoiling of replicating bacterial
DNA
 Have little effect on eukaryotes or
viruses
 May act against replication of
mitochondrial DNA in some eukaryotes
› Nucleotide analogs or nucleoside analogs
 Anti-AIDS drugs
 Molecules with structural similarities to
the normal nucleotide building blocks of
nucleic acid
 Distort the shapes of the nucleic acid
molecules and prevent further
replication, transcription, or translation
 Often used against viruses because viral
DNA polymerases are tens to hundreds
of times more likely to incorporate
these nonfunctional nucleotides into
nucleic acids than is human DNA
 Effective against rapidly dividing cancer
cells
› Rifampin
 Function by binding to and inhibiting
the action of RNA polymerase during
synthesis of RNA from a DNA template
 Bind more rapidly to prokaryotic RNA
polymerase than to eukaryotic RNA
polymerase
 More toxic to prokaryotes than to
eukaryotes
› Clofazimine
 Binds to bacterial DNA and evidently
prevents normal transcription
› Rifampin and clofazimine are used
primarily against species of mycobacteria
such as M. tuberculosis (tuberculosis) and
M. leprae (leprosy)
› Pentamidine and propamidine
isethionate
 Bind to protozoan DNA, inhibiting DNA
replication and RNA transcription
› Reverse transcriptase inhibitors
 Emtricitabine – a part of AIDS cocktail
 Act against reverse transcriptase –
which is an enzyme HIV uses early in
its replication cycle to make DNA
copies of its RNA genome
 Do not harm people because humans
lack reverse transcriptase
Prevention of Virus Attachment, Entry, or
Uncoating
› Attachment analogs:
a. Pleconaril
 Synthetic antagonist of the
receptors of picornaviruses
 Blocks viral attachment and deters
infections
b. Arildone
 Synthetic antiviral that prevents
removal of poliovirus capsids
(uncoating)
Clinical Considerations in Prescribing
Antimicrobial Drugs
› Characteristics of an ideal antimicrobial
agent to treat an infection or disease:
 Readily available
 Inexpensive
 Chemically stable (so that it can be
transported easily and stored for long
periods of time)
 Easily administered
 Nontoxic and nonallergenic
 Selectively toxic against a wide range of
pathogens
› No agent has all these qualities, so doctors
and medical laboratory technicians must
evaluate antimicrobials with respect to
several characteristics:
 Types of pathogens which they are
effective
 Effectiveness (dosage required)
 Routes by which they can be
administered
 Overall safety
 Side effects

Spectrum of Action
› Number of different kinds of pathogens a
drug act against
a. Narrow-spectrum drugs
 Effective against few organisms
b. Broad-spectrum drugs
 Effective against many different
kinds of pathogens
 May allow serious secondary
infections by transient pathogens
or superinfections by members of
the normal microbiota unaffected
by the antimicrobial
 Killing of normal microbiota
reduces microbial antagonism –
competition between normal
microbes and pathogens for
nutrients and space
Effectiveness
Diffusion Susceptibility Test
› Also known as Kirby-Bauer Test
› Uniformly inoculating a Petri plate with a
standardized amount of the pathogen in
question
› Small disks of paper containing standard
concentrations of the drugs to be tested are
firmly arranged on the surface of the plate
› Zone of inhibition
 a clear area where bacteria do not
grow
 measured as the diameter of the clear
region.
› If all antimicrobials diffused at the same
rate, then larger zone of inhibition would
indicate a more affective effective drug
› The size of zone inhibition must be
compared to a standard table for that
particular drug before accurate
comparisons can be made
› Enables scientists to classify pathogens:
 Susceptible
 Intermediate
 Resistant
Minimum Inhibitory Concentration (MIC) Test
› Quantitively express its potency often using
the unit µg/ml
› The smallest amount of the drug that will
inhibit growth and reproduction of the
pathogen
› Tests:
a. Broth dilution test
 A standardized amount of bacteria is
added to serial dilutions of
antimicrobial agents in tubes or wells
containing broth
 After incubation, turbidity indicates
bacterial growth; lack of turbidity
means bacteria were either inhibited
or killed by the antimicrobial agent
b. Etest
 Combines aspect of an MIC test and
diffusion susceptibility test
 Involves placing a plastic strip
containing gradient of the
antimicrobial agent being tested on
a plate uniformly inoculated
 After incubation, an elliptical zone
inhibition indicates antimicrobial
activity, and the minimum inhibitory
concentration can be noted where
the zone of inhibition intersects a
scale printed on the strip
Minimum Bactericidal Concentration (MBC)
Test
› Similar to the MIC test, but MBC test
determines the amount of drug required to
kill the microbe rather than just the amount
to inhibit it
› Samples taken from clear MIC tubes are
transferred to plates containing a drug-free
growth
› The appearance of bacterial growth in these
subcultures indicates that at least some
bacterial cells survived that concentration
of the antimicrobial drug
› The lowest concentration of drug for which
no growth occurs in the subcultures is the
minimum bactericidal concentration
Routes of Administration
› External infections:
a. topical or local administration
 drugs can be applied directly
› Internal infections:
a. Oral route
 Requires no needles and is self-
administered
 The drug concentrations achieved
in the body are lower than occur via
other routes of administration
b. Intramuscularly (IM)
 Via hypodermic needle into muscle
allows a drug to diffuse slowly into
the many blood vessels within
muscle tissues
 The concentration of the drug in the
blood is never as high as that
achieved in by IV administration
c. Intravenously (IV)
 Delivers the drug directly to
bloodstream either through needle
or a catheter
  The amount of a drug in the blood is
initially very high
› Physicians can administer nonantimicrobial
chemicals that prolong an antimicrobial’s
life span in the body
› Physicians must consider how the blood
distributes the antimicrobial agents to
infected tissues
Safety and Side Effects
Toxicity
› Many antimicrobials have toxic side effects
› Drugs may be toxic to the kidneys, the liver,
or nerves
 Polymyxin and aminoglycosides have
fatally toxic effects on kidneys
 Metronidazole (Flagyl), a drug
effective against a variety of anaerobic
protozoa and bacteria, may cause a
harmless temporary condition called
“black hairy tongue”
› Doctors must be especially careful when
prescribing drugs for pregnant women
because many drugs that are safe for adults
can have adverse effects when absorbed by
a fetus
 Tetracyclines form complexes with
calcium that can become incorporated
into bones and developing teeth,
causing malformation of the skull and
stained, weakened tooth enamel
› Therapeutic index (TI)
 Ratio comparing the largest dose of the
drug that is not toxic to the drug’s
smallest effective dose
› Therapeutic window
 Range of concentrations of the drug
that are effective without being
excessively toxic
Allergies
› Some drugs trigger allergic immune
response to sensitive patients
Disruption of Normal Microbiota
› Drugs that disrupt normal microbiota and
their microbial antagonism may allow
opportunistic pathogens to proliferate as
secondary infections
› Become an opportunistic pathogen and can
overgrow, causing a disease
Resistance to Antimicrobial Drugs
The Development of Resistance in
Populations
› A population may contain a few individuals
that are naturally either partially or
completely resistant
› Two ways in which bacteria acquire
resistance:
a. New mutations of chromosomal genes
b. By acquiring resistance genes on
extrachromosomal pieces of DNA
called R Plasmids via transformation,
transduction, or conjugation
› In the absence of an antimicrobial drugs,
resistant cells are usually less efficient than
their normal neighbors because they must
expend extra energy to maintain resistance
genes and proteins
› When an antimicrobial agent is present, the
majority of microbes, which are sensitive to
the antimicrobial, are inhibited or die while
the resistant microbes continue to grow
and multiply
› Resistant organisms soon replace the
sensitive ones as the majority in the
population
› The presence of an antimicrobial agent
does not produce resistance but instead
selects for the replication of resistant
microbes that were already present in the
population
Mechanisms of Resistance
a. Resistant cells may produce an enzyme that
destroys or deactivates the drug
b. Resistant microbes may slow or prevent the
entry of the drug into the cell
c. Resistant cells may alter the target of the
drug so that the drug either cannot attach
to it or binds it less effectively
d. Resistant cells may alter metabolic
chemistry, or they may abandon the
sensitive metabolic step altogether
e. Resistant cells may pump the antimicrobial
out of the cell before the drug can act
(efflux pump)
f. Bacteria within biofilms resist
antimicrobials more effectively than free-
living cells
g. Some resistant strains of the bacterium
Mycobacterium tuberculosis produce Mfpa
protein – binds to DNA gyrase in place of
DNA, depriving fluoroquinolone of its target
site
Multiple Resistance and Cross Resistance
› Pathogen can acquire resistance to more
than one drug at a time especially when
resistance is conferred by R plasmids,
which are exchanged readily among
bacterial cells
› Multiresistants strains of bacteria
 develop in hospitals and nursing
homes
 constant use of many kinds of
antimicrobial agents eliminates
 sensitive cells and encourages the
development of resistant strain
› Multiple-drug-resistant pathogens
 Resistant to three or more different
types of antimicrobial agents

› Cross resistant
 Resistance to one antimicrobial
agent may confer resistance to
similar drugs

Retarding Resistance
a. Maintain sufficiently high concentrations of
the drug in a patient’s body for a long
enough time to inhibit pathogens, allowing
the body’s defenses to defeat them
b. Use antimicrobial agents in combination so
that pathogens resistant to one drug will be
killed by other drugs
 Enhances the effect of a second drug by
synergism
c. Limit the use of antimicrobials to necessary
cases
d. Developing semisynthetic drugs, perhaps
by adding different side chains to the
original molecule
 Bacteriocins – antibacterial proteins
coded by bacterial plasmids