ANTIMICROBIAL DRUGS

MECHANISM OF ACTION AND RESISTANCE

 Principles of antimicrobial therapy

 Bactericidal & bacteriostatic activity
 Mechanisms of action:
- Inhibition of cell wall synthesis
- Inhibition of protein synthesis
- Inhibition of nucleic acid synthesis
- Alteration of cell membrane function
- Additional drug mechanisms
- Chemoprophylaxis & Probiotics
- Resistance mechanisms

PRINCIPLES OF ANTIMICROBIAL THERAPY

 Selective toxicity: selective inhibition of the growth of the
microorganism without damage to the host
 Selective toxicity is achieved by differences between the metabolism and
structure of microorganism and human cells
THE MOST IMPORTANT CONCEPT UNDERLYING ANTIMICROBAIL THERAPY IS
SELECTIVE TOXICITY

 Differences of bacterial cell and human cell, on the basis for

the action of clinically effective drugs:
1- cell wall
2- ribosomes
3- nucleic acids
4- cell mebrane
 

 Antibacterial drugs are more than antiviral drugs

 Viruses use many of the normal cellular functions of the host for growing
 Design a drug that will selectively inhibit viral replication but not damage
to host cell is difficult

Broad – spectrum antibiotics: 

 active against several types of microorganisms
e.g.tetracyclines active against gram negative rods, chlamydia, mycoplasma,
rickettsia
Narrow – spectrum antibiotics:
 Active against one or very few types of microorganism
e.g. vancomycin is used certain gram positive cocci, staphylococci, enterococci

VANCOMYCIN INHIBITS THE SYNTHESIS OF CELL WALL

TETRACYCLINE INHIBITS PROTEIN SYNTHESIS OF 30 SRIBOSOMAL
SUBUNIT

Bactericidal activity:
  Drugs kill bacteria
 Used in infection that immediately life-threatening 
Bacteriostatic activity:
 Drugs inhibits their growth, do not kill
 Bacteria can grow again when the drug is withdrawn
 Host defence mechanisms, such as phagocytosis are required for killing bacteria

INHIBITION OF BACTERIAL CELL WALL SYNTHESIS

 PENICILLINS
 CEPHALOSPORINS
 CARBAPENEMS
 MONOBACTAMS
 VANCOMYCIN
 CYCLOSERINE & BACITRACIN

INHIBITION OF BACTERIAL CELL WALL SYNTHESIS

Penicillin & Cephalosporins

 Bactericidal, but kills cells only when they are growing 
  Act by inhibiting an enzyme in the synthesis of peptidoglycan
 Called β lactam drugs (β lactam rings)
 Two additional factors involve in the action of penicillin
 CLEAVAGE OF THE RING BY PENICILLINASES (BETA LACTAMESES)
INACTIVATES THE DRUG

Penicillin & cephalosporins

1- Penicillin binds to a receptor in bacterial cell membrane and wall -penicillin binding
protein (PBP) 
 Changes in PBP are responsible of organism’s becoming resistant to penicillin
2-Autolytic enzymes (called murein hydrolyses, murein=peptidoglycan) are activated in
penicillin-treated cells and degrade peptidoglycan
 Benzylpenicillin (penicillin G)-composed of 6-aminopenicillanic acid+benzyl side
chain
 Available in three forms:
1- Aqueous penicillin G :metabolized more rapidly

2- Procain penicillin G: metabolize slowly, less painful in im. injection

3- Benzathine penicillin G: metabolize very slowly called “depot” preperation

THE MOST IMPORTANT NATURALLY OCCURİNG COMPOUND IS BENZYLPENICILLIN

Benzylpenicillin (penicillin G)
 The most widely used effective antibiotic
 Disadvantages
1-limited effectiveness for Gr (-) rods (due to inability to penetrate to outer
membrane)
2-hydrolysis by gastric acid-cannot be taken orally
3-inactivation by β-lactameses
4-hypersensitivity, anaphylaxis (in all type of penicillins)
THERE ARE SOME CHANGES IN THE PENICILLINE CHAIN FOR OVERCOME TO THIS
DISADVAANTAGES

There are some changes in the penicilline chain for overcome to this disadvantages:
1-Ampicillin & amoxicillin: 
 Increased effectivity against Gr (-) rods, by a series of chemical changes in the
side chain 
e.g.carbenicillin, ticarcillin, piperacillin
 As the activity against Gr (-) increases; the activity against Gr(+) bacteria
decreases
2-Penicillin V-Ampicillin: Minor modifications of the side chain
 Prevent hydrolysis and allows the drug to be taken orally 
3- Methicillin, Nafcillin
 Inactivation of penicillin G by β lactamases is preventable by accessing of the
enzyme to β lactam ring by modification of the side chain (adding some aromatic
rings, methyl or ethyl)
 By adding β lactamases inhibitors (clavulonic acid & sulbactam)
 Amoxicillin+clavulanic acid
 Ampicillin/Sulbactam

INHIBITION OF BACTERIAL CELL WALL SYNTHESIS

Cephalosporins (CF)
  β-lactam drugs, act in the same manner as penicillins
 Derived from 7-aminocephalosporanic acid, originally isolated Cephalosporium
mold
 Bactericidal agents inhibit cross-linking of peptidoglycan
 First generation cephalosporins active against Gr (+) cocci
  New synthesized CF 2.3.4.5. generation
 Having expanded coverage against Gr (-) rods
 Effective against a broad range of organisms
 Generally well tolerated-fewer hypersensitivity reactions (10% chance of)
SIMILAR TO PENICILLINS NEW CEPHALOSPORINS WERE SYNTHESİIZED
WITH EXPANSION OF ACTIVITY AGAINST GR (-) RODS AS THE GOAL.

OTHER β LACTAMS
Carbapenems (imipenem-ertapenem-meropenem)
 Structurally different from Pen. and CF
 Imipenem-widest spectrum 
 IMP-excellent bactericidal activity against many Gr (+), Gr (-) and anaerob
bacteria
 Use in treating infections caused by Gr (-) rods which produce extended-
spectrum β lactameses (make them resistant to pen and CF)
 “Drugs of last resort” against multiresistant organisms
 IMP. HAS THE WIDEST SPECT. OF ACTIVITY OF THE BETA LACTAMS
 G (+): STREPTOCCI, STAPH. GR(-) COC NEISSERIA, GR(-) ROD:
PESUDOMONAS, HAEMOPHILUS, E. COLİ, ANAEROBS: BACTEROİDES
CLOSTRIDIUM
Monobactams (Aztreonam)
 Active against many Gr(-) rods
 Enterobacteriaceae and Pseudomonas
 Resistant to most β lactamases
 Useful in patients who are hypersensitive to pen- because no cross- reactivity

MECHANISM OF RESISTANCE
 β lactamases: An enzyme that breaks β lactam ring in penicillin (penicillinase)
 or cephalosporins (cephalosporinase)
  Hydrolysis of the ring protects the bacteria from antimicrobial activity
General mechanisms:
Beta lactams penetrate into the gr (-) through porin channels,                     
1. Failure of antibiotics to penetrate through the outer membrane (mutation of the
porin channels- P.aeruginosa to IMP)
2. Failure to bind to the target side (penicillin binding protein-PBP)
Hydrolysis of the antibiotic by β lactamases
BETA LACTAMS PENETRATE INTO THE GR (-) THROUGH PORIN CHANNELS.
MUTATION OF THE PORIN PROTEINS RENDER THE ORGANISM RESISTANT TO BETA
LACTAM AGENTS

VANCOMYCIN
 A glycopeptide inhibits cell wall peptidoglycan synthesis by blocking
transpeptidation (difference from β lactam drugs)
 Effective against certain Gr (+) bacteria
 Inactıve against Gr (-), 
 Too large to pass outer membrane and reach to peptidoglycan target site
 Used in treatment of S.aureus infections resistant to penicillinase resistant
penicillins (methicillin resistant S.aureus-MRSA)
 The mechanism of resistance to vancomycin is, modification of drug target in
bacteria
Cycloserine 
-Inhibit the synthesis of the cell wall
 Second-line drug in treatment of tbc
 Resistance is mediated by:
-either reduced drug uptake into the cell
-alteration of target sites
Bacitracin
 Used for skin infections too toxic for systemic use
 Resistance is due to failure of drug to penetrate into the bacterial cell
 INHIBITION OF PROTEIN SYNTHESIS
 Inhibit protein synthesis in bacteria not in human
 Selectivity due to differences between bacterial and human ribosomal proteins,
RNA’s and enzymes
 Bacteria have 70S ribosomes-50S,30S subunits
 Whereas human cells have 80 S- 60S, 40S subunits
SEVERAL DRUGS INHIBIT PROTEIN SYNTHESIS İN BACTEIA WITHOUT
SIGNIFICANTLY INTERFERING WITH PROTEIN SYNTHESIS IN HUMAN CELLS
Drugs That Act on the 30S Subunit

Aminoglycosides
 Bactericidal drugs
 Against many Gr (-) rods
 Inhibit the bacterial protein synthesis by irreversibly binding to the ribosomes
 Streptococci and anaerobs are resistant
 Gentamicin and tobramycin have broad spectrum of activity
 Tobramycin is slightly more active to P.aeruginosa
 Netilmicin is less active
 All 3  is used to treat in systemic infections caused by Gr (-) bacteria
 Streptomycin has been used to treat tbc
 Amikacin is used to treat infections caused by gr (-) bacteria that are resistant
to other AGs.
 AGs have certain limitations in their use:
 -toxic effect both on kidneys, auditory and vestibuler portions of 8. cranial
nerve
 -poorly absorbed from GIT, cannot be given orally
 -poorly penetrate the spinal fluids, must be given intrathecally in treatment of
meningitis
 -ineffective against anaerobes, they require oxygen for transporting to bacterial
cell

Resistance can develop to Ags’ in 3 ways:

1.Mutation of the ribosome binding site
- This is relatively uncommon except Enterococcus
2.Decreased antibiotic uptake into the bacterial cell
-occasionally observed in Pseudomonas, more common in anaerobes (AG uptake by cell is
oxygen dependent)
3.Enzymatic modification-most common
ENZYMATIC MODIFICATION( PHOSPHORYLATION, ADENYLATION,
ACETYLATION) OF AMINOAND HYDROXYL GROUPS OF AG IS MOST COMMON
RESISTANCE MECHANISM
Tetracyclines
 Bacteriostatic activity against Gr (+) and Gr (-) bacteria, mycoplasma, chlamydiae,
rickettsiae
 Inhibit protein synthesis by binding 30S ribosomal subunit
 Selectivity is based on its greatly increased uptake into susceptible bacterial
cells compared with human cells
 Resistance to the TC is due to increased efflux of antibiotic from the cell
 e.g. doxycycline, minocycline, oxytetracycline have similar antimicrobial activity
 Have low toxicity but some important side effects
1.Suppression of the normal flora of GIT-lead diarrhea overgrowth by drug-resistant
bacteria and fungi
2.Suppression of Lactobacillus in vaginal flora,rise in pH, allows C.albicans
vaginitis
3.Deposition of drug in developing teeth, so brown staining of teeth of fetuses and
young children 
Tigecycline
 Structure is similar to TC and same mechanism of action-bind to 30S ribosomal
subunit
 Used to treat skin infections caused by MSSA,MRSA, E.coli, VRE, Bacteroides
fragilis
 Treat complicated intra-abdominal infections caused by facultative and anaerobic
bacteria
Drugs That Act on the 50S Subunit
Chloramphenicol
 Active against Gr (+), Gr (-) bacteria, anaerobes
 Bacteriostatic against S.thphi 
 Bactericidal activity against H.influenzae,S.pneumoniae, N.meningitidis
 Side effect: bone narrow toxicity
  CH is a simple molecule of nitrobenzene
 Is bone narrow depressant
 BACTERICIDAL ACTIVITY AGAINST
H.INFLUENZAE,S.PNEUMONIAE, N.MENINGITIDIS THEY ALL
CAUSE MENIGITIS.
 Specific toxic manifestation is “gray baby” syndrome
 Due to reduced activity of an enzyme (which is responsible of detoxification of
CH) in infants
 Resistance is observed in bacteria producing an enzyme

Macrolides

 Bacteriostatic drugs

 Azitromycin: genital tract infections, respiratory infections

 Erythromycin: similar activity, but shorter half life, more adverse effects on
GIT
 Clarithromycin: used in primarily in treatment of Helicobacter, prevention of
M.avium-intracellulare infections

AZITROMYCIN: IS USED TO TREAT GENITAL TRACT INFECTIONS CAUSED BY

C.TRACHOMATIS, AND RESPIRATORY INF. CAUSED BY LEGIONELLA MYCOPLASMA,
C.PNEUMON.STR.PNEUMON
ERIROMYCIN MUST BE TAKEN MORE FREQUENTLY

Clindamycin
 Most useful bacteriostatic drug against anaerobes
 The most important side effect is pseudomembranous colitis
 Resistance to Erythromycin develops by modification of ribosomal 23SRNA
 Resistance to Clindamycin is mediated by induction of an enzyme
PSEUDOMEMBRANOUS COLITIS PATHOGENESIS IS SUPPRESSION OF NORMAL
FLORA OF BOWEL BY THE DRUG AND OVERGROWTH OF A DRUG RESISTANT
C.DIFFICILE STRAIN.EXOTOXİN OF ORGANISMPRODUCES PSEUDOMEMBRANE
IN COLON AND SEVERE BLOODY DIARRHEA
Linezolid
 Useful for treatment of VRE, MRSA, pen. resistant pneumococci
 Bacteriostatic against 
 enterococci & staphylococci, 
 Bactericidal against 
 pneumococci
Binds 23SRNA in the 50 S subunit, and inhibit protein synthesis
Telithromycin
 First clinically useful member of ketolide group
 Similar to macrolides ,different chemically
 Organisms resistant against macrolides may be sensitive to telithromycin
 Wide spectrum of activity
 Used in treatment of community-acquired pneumoniae, bronchitis, sinusitis
Streptogramins
 Combination of quinopristin and dalfopristin used for bloodstream infections
 Approved for use in infections caused by S.pyogenes, MRSA, MRSE, pen R
S.pneumoniae
 Mode of action is different from all other drugs that inhibit protein synthesis
 So no cross-reaction between other drugs
Retapamulin
 First member of a new class pleuromutilis
 Inhibit protein synthesis by binding 23SRNA of the 50S subunit
 Topical antibiotic, for skin infections
Caused by S.pyogenes, MSSA

INHIBITION OF NUCLEIC ACID SYNTHESIS

1.Inhibition of Precursor Synthesis
Sulfonamides
 Bacteriostatic drugs produced by chemical synthesis
 Either alone or combination with trimethoprim
 Useful  to treat UTI caused by E.coli
 Otitis media caused by S.pneumoniae, H.influenzae
 Shigellosis, toxoplasmosis
 Mode of action: is to block the synthesis of tetrahydrofolic acid 
  Which is required in the synthesis of nucleic acid precursors-adenine, guanine
and thymine
 Infrequently causes side effects
 However, drug related fever, rashes, photosensitivity, bone marrow suppression
may occur

Trimetoprim
 Mostly used with sulfamethoxazole
 Inhibit the synthesis of tetrahydrofolate
 Advantage of combination:
-bacterial mutants resistant to one drug will be inhibited by the other
-two drugs act as synergistically
(When used together, the effect is greater than used each drug seperately )
Trimethoprim/sulfamethoxazole -TMP/SMX is used in UTI, shigellosis, P.carinii
pneumoniae
2.Inhibition of DNA Synthesis
Fluoroquinolones
 Bactericidal, that block bacterial DNA synthesis by inhibiting DNA gryrase
 Ciprofloxacin, levofloxacin, norfloxacin, ofloxacin
 Active against organisms that cause UTI
Lower respiratory tract infections
Intestinal tract infections
Skeletal and soft tissue infections
 Fluoroquinolones should not be given to pregnants and children under 18
 Damage to growing bone and cartilage
 Adverse effects: 
peripheral neurophaty
e.g.pain, burning, numbness, tingling in the arms and legs
DNA gryrase consist of alpha-beta subunit-
Principal of bacterial resistance is alteration of the alpha subunit
3.Inhibition of mRNA Synthesis
Rifampin
 Used in treatment of tbc in combination
 Prophylaxis in close contacts with meningitis
  Used with combination other drugs because of high rate resistance
 Blocks mRNA synthesis by bacterial RNA polymerase
 It is red, so urine, saliva, sweat may be red when using the drug-harmless

ALTERATION of CELL MEMBRANE FUNCTION

 Few, because it’s difficult to provide selective toxicity-structure and chemical
similarities of bacterial and human cell
Polymyxins-polypeptide antibiotic
 Most useful compound polymyxin E (colistin)
 Active against Gr (-) rods esp. P.aeruginosa, A.baumanii
 Disrupt the phospholipid structure of cell membrane
FAMILY OF POLYPEPTIDE ANTIBIOTIC
Daptomycin
 Cyclic polypeptide
 Disrupts Gr (+) cocci cell membranes
 Bactericidal for:
MRSA, S.aureus, VRSA
S.pyogenes, E.faecalis, VRE
 Used to treat complicated skin and soft tissue infections

ADDITIONAL DRUG MECHANISMS

1.Antibacterial Activity
Isoniazid (INH-isonicotinic acid hydrazide)
 Bactericidal highly specific for M.tuberculosis
 Penetrate to human cell so, effective against the organism in the macrophages
 Inhibits mycolic acid synthesis-specific for mycobacterium, nontoxic for human
 Side effect is liver toxicity

INHIBITS MYCOLIC ACID SYNTHESIS- WHICH EXPLAINS WHY SPECIFIC FOR

MYCOBACTERIUM, NONTOXIC FOR HUMAN

Metronidazole 
Bactericidal against anaerobs
 Mode of action
-Act as an electron sink
-Inhibit the DNA synthesis
Etambutol
 Bacteriostatic against M.tuberculosis, atypical mycobacteria
 Inhibits a link between mycolic acid and peptidoglycan layer of organism
BY ACCEPTING ELECTRONS THE DRUG DEPRIVES THE ORGANISM OF REQUIRED
REDUCING POWER

Pyrazinamide (PZA)
 Bactericidal in treatment of tbc
 Inhibits fatty acid synthetase – prevent the mycolic acid synthesis
CHEMOPROPHYLAXIS
Antimicrobials used to prevent diseases
1.Prior to surgery
2.In immunocompromised patients
3.Patients exposed to certain pathogens
PROBIOTICS
 Live, nonpathogenic bacteria
 Treatment or prevention of certain human diseases
 e.g. Lactobacillus rhamnosus reduce nosocomial diarrhea in children
A yeast-Saccharomyces boulardii reduces the risk of diarrhea caused by
C.difficile

The Importance of Resistance

 Bacteria acquire resistance sooner or later

 Important for the patient and doctor

 Extended hospitalization
 High death risk
 Antimicrobial resistance…..!!!!!
 More broad spectrum antibiotic
 More toxic
 More expensive antibiotic

PRINCIPLES of ANTIBIOTIC RESISTANCE

1.Bacteria produce enzymes that inactivate the drug (β lactamases)
2.Bacteria synthesize modified targets against the drug reduced effect
(mutation in 30S ribosomal subunit-streptomycin)
3. Bacteria reduce permeability to drug, so drug cannot achieve effective intracelluar
concentration  (changes in porins reduce the amount of penicillin entering the
bacterium)

4.Bacteria actively export drugs using “multidrug resistance pumps” (MDR)

NONGENETIC BASIS OF RESISTANCE

1.Bacteria can be walled of within abscess, so drug cannot penetrate-surgical drainage
2.Bacteria can be resting state (not growing),insensitive to cell wall inhibitors
Dormant-tbc
3.Sometimes organisms may lose their cell wall-protoplast, so insensitive to cell-wall
active drugs

4.Presence of foreing bodies-catheters, surgical implants

5.Several artifacts
-Administration of wrong drug, 
 -wrong dose,
 -failure of drug to reach the appropriate site
 -failure of patient to take the drug

OVERUSE & MISUSE OF ANTIBIOTICS

Serious outbreaks of diseases caused by multiresistant antibiotics
Main points of this are:
1.Some physicians use multiple antibiotics instead of using one would be sufficient
2.Solding the drugs over the counter to public
3.Antibiotics are used in animal feed to prevent infections. This cause resistant
organisms

USE OF ANTIBIOTIC COMBINATIONS

Several instances two or more drugs commonly given:
1.To treat serious infections before identity of the organism is known
2.To achieve a synergistic inhibitory effect against certain organisms
3.To prevent the emergence of resistant organism (If bacteria become resistant to one
drug, second will kill)