This first part of the lecture covering pharmacology of antibiotics, we are going to discuss cell wall

synthesis inhibitorsand cell membrane integrity disruptors. But first things first, let's define antibiotics
and let's classify them. So antibiotics are broadly defined as chemical agents that kill or inhibit the
growth of microorganisms. Antibiotics may be classified as broad spectrum, meaning they act
against a wide range of microorganisms, or as narrow spectrum, meaning they act against very few
types of microorganisms. Furthermore, antibiotics may be categorized as bactericidal, meaning they
kill bacteria, or as bacteriostatic, meaning they only stop bacteria from growing. Selection of
antibiotic depends largely on clinical manifestation of the infection as well as the patient profile, and
it's often guided by the cultural sensitivity results. The Kierbie Bauer method is one of the most
commonly performed tests that helps to guide selection of an effective antibiotic, while the dilution
test is commonly performed to determine the lowest concentration of antibiotic that inhibits visible
bacterial growth, known as Minimum Inhibitory Concentration, or MIC, and the lowest concentration
of antibiotic that kills at least 99.9 % of bacteria, known as the Minimum Bactericidal Concentration,
or MBC. Now, let's dive a little deeper and take a closer look at how antibiotics work.

Based on their mechanism of action, antibiotics can be divided into five broad categories. Number
one, cell wall synthesis inhibitors. Number two, cell membrane integrity disruptors. Number three,
nucleic acid synthesis inhibitors. Number four, protein synthesis inhibitors. Number five, metabolic
pathway inhibitors. Now, let's discuss these one by one in detail, starting with cell wall synthesis
inhibitors. So the cell wall is essential for the growth and survival of bacteria. It gives the bacterial cell
its shape and protects it against spontaneous cell lysis due to the high internal osmotic pressure that
results from high concentration of proteins within the bacterial cytoplasm. The vast majority of
bacteria have one of two different types of cell wall. The first one is called ground negative, and it is
composed of the outer membrane linked by lipoproteins to a thin inner layer of peptide or glycan. The
second one is called gram positive. It is composed of many interconnected layers of peptide or
glycan, and it lacks the outer membrane. Now, peptide or glycan is what gives both cell wall types the
rigid and protective qualities. It consists of glycan chains of alternative N acetylglucosamine, NAG for
short, and an acetylmuramic acid, NAM, with short peptide chain attached to it.

The biosynthesis of peptide or glycan is mediated by transpeptidase enzyme, also known as penicillin
binding proteins. Specifically, penicillin binding proteins catalyze the final transpeptidation reaction
that results in formation of bond between the last lycin residue of one peptate o glycan and the
terminal alanine on the other strand. Now, in order for bacteria to grow and divide, a new cell must be
continuously built this way. So this is where inhibitors of cell was synthesis come into play. Most of
antibiotics belonging to this group are characterized by beta lactam ring at the core of their structure,
which resembles substrate for penicillin binding protein. When penicillin binding protein binds to beta
lactam ring portion of the drug, covalent bond is formed, resulting in permanently blocked active site.
This makes the enzyme unable to perform their role in cell wall synthesis, which in turn leads to death
of bacteria due to osmotic instability or autolysis. Now, the beta lactam rank is part of the structure of
several antibiotic families, namely penicillins, Cephalosporans, Carbapandams, and Monobactams.
Collectively, we call them beta lactam antibiotics. Here are some examples of beta lactams. Due to
the large number of antibiotics that belong to this family, keep in mind that this diagram is not meant
to be exhausted.

So all looks good up to this point. We have all these powerful antibiotics that can easily kill all harmful
bacteria, right? Well, not so fast. Unfortunately, over the years, exposure to antibiotics provided
bacteria with selective pressures, which led to emergence of different resistance mechanisms. The
most common mechanism for drug resistance to beta lactam antibiotics is bacterial synthesis of
beta lactamases. Beta lactamases are enzymes, produced by certain types of bacteria that simply
break the beta lactam ring and thus destroy antibacterial activity. In an effort to fight back against this
resistance, scientists were able to develop beta lactamase inhibitors that irreversibly bind to and
inhibit beta lactamase enzymes. The use of beta lactamase inhibitors in combination with beta
lactam antibiotics is currently the most successful strategy that we have to combat this specific
mechanism of resistance. However, I would like to point out two exceptions here, which are
carbapenams and monobactams. Unlike penicillins and Cephalosporans, they don't need to be
combined with beta lactamase inhibitors because they have modified beta lactam rings in their
structures that provide them with significant resistance to beta lactamases. Examples of beta
lactamase inhibitors are Avibactam, Clavulanic acid, Sobactam, and Tazobactam. Now, when it
comes to side effects, all beta lactam antibiotics are likely to cause nausea, vomiting, and diarrhea.

In addition to that, small number of patients may experience allergic reactions, ranging from mild
rashes to life threatening anaphylaxis. Now, beta lactams are not the only antibiotics that interfere
with synthesis of the bacterial cell wall. For other antibiotics that you may frequently encounter,
namely fosfomycin, Cyanide, Cyclocerin, Vencomycin, and Bacitracin also disrupt cell wall synthesis.
However, they accomplish that through a different mechanism. In order to gain better understanding
of how these antibiotics work, first, we need to take a closer look at the encematic steps involved in
cell wall synthesis. So the first major step of the cell wall synthesis involves the cytoplasmic enzyme
in all pyrovate transfers, abbreviated as M UR A. M UR A catalyzes the addition of fosfowinol pyridate,
abbreviated PEP, to UDP an acetylglucosamine to form UDP an acetyl muramic acid, to which then
three amino acids are sequentially added. The next crucial step involves two enzymes, first D alanine
Resemase that converts L alanine into D alanine, and the second D alanine D alanine Ligase that joins
two D alanine molecules which are then incorporated into the growing peptidoglycan precursor. Next,
with the help of translocase enzyme, peptidoglycan precursor is transferred to the lipid carrier called
Andacapernil Pyrophosphate, also known as Bectoprenol.

This is followed by sequential addition of N acetyl Glucosamine along with five amino acid molecules.
Now, once this cell building block is transported across the inner membrane, penicillin binding
proteins catalyze the final step of polymerisation of N acetyl Miramic acid and N acetylglucosamine
complexes via transglycosylation and cross linking of chains via transpeptidation. Also at the very
end, the Bectopranol lipid carrier gets defosforulated, which enables it to perform another round of
transfer. Now, let's go back to our four antibiotics and let's examine how they disrupt the cell wall
synthesis machinery, starting with fosfomycin. Fosfomycin acts in the first cytoplasmic step of the
cell wall synthesis by irreversibly inhibiting MuA enzyme. This in turn prevents the formation of
peptide or glycan precursorand eventually leads to bacterial cell death. Our second antibiotic,
cyclocerin, comes into play at the next crucial step of the synthesis. Because of its chemical
resemblance to D alalene, cyclocerin comparatively inhibits both L Alanine Resemase and D alanine
dalanine ligase. When both of these enzymes are inhibited, then D alanine residuals cannot be formed
and previously formed, the Alanine molecules cannot be joined together. Again, the formation of
peptide or glycan precursor is disrupted, which eventually leads to death of bacteria.

Now, let's move on to our third antibiotic that is vencomycin. Vencomycin belongs to a small family of
antibiotics called glycopeptides that includes few other drugs that work in similar way. Unlike
fosfomycin and cyclosine, vencomycin works in the late stages of cell walls synthesis. Specifically,
vencomycin interferes with both transpeptidation and trisglacosylation during peptide o glycan
assembly by binding to 2D alanine residue at the top of the peptide chains. This binding in turn
prevents linking of long polymers of an acetylchloride.