Cell Wall Inhibitors: Zarqa University Pharmacy School Clinical Pharmacy and Therapeutics Department Pharmacology III

Zarqa University
Pharmacy School
Clinical Pharmacy and Therapeutics Department
Pharmacology III
Cell Wall Inhibitors
Dr. Fares Al Bahar

Objectives
 To be able to discuss some antimicrobial drugs selectivity

interfere with synthesis of the bacterial cell wall- a structure that
mammalian cells do not possess.
 To be able to understand the most important members of cell

wall inhibitors group of drugs, such as β-lactams, vancomycin
and daptomycin.
 To be able to understand the mechanism of action, antibacterial

spectrum, resistance, pharmacokinetics and adverse effects of
these drugs.
Cell Wall Inhibitors 2

Contents
 Overview
 Telavancin
 Penicillins
 Fosfomycin
 Mechanism of action
 Polymyxins
 Antibacterial spectrum
 Resistance
 Pharmacokinetics
 Adverse reactions
 Cephalosporins
 Antibacterial spectrum
 Resistance
 Pharmacokinetics
 Adverse effects
 Other β-lactam antibiotics
 Carbapenems
 Monobactams
 β-lactamase inhibitors
 Vancomycin
 Daptomycin
I. Overview
 Some antimicrobial drugs selectively interfere with synthesis of the

bacterial cell wall—a structure that mammalian cells do not possess.
 The cell wall is composed of a polymer called peptidoglycan that

consists of glycan units joined to each other by peptide cross-links.
 To be maximally effective, inhibitors of cell wall synthesis require

actively proliferating microorganisms. They have little or no effect on
bacteria that are not growing and dividing.
 The most important members of this group of drugs are the β-lactam
antibiotics (named after the β-lactam ring that is essential to their
activity), vancomycin, and daptomycin.
 Figure 38.1 shows the classification of agents affecting cell wall

synthesis.

Chapter 38 Summary of antimicrobial agents affecting cell wall synthesis.
Figure 38.1a
Copyright © 2015 Wolters Kluwer • All Rights Reserved

Chapter 38 Summary of antimicrobial agents affecting cell wall synthesis.
Figure 38.1b

II. Penicillins
 The penicillins are among the most widely effective and the least toxic
drugs known, but increased resistance has limited their use. Members
of this family differ from one another in the R substituent attached to
the 6-aminopenicillanic acid residue (Figure 38.2).
 The nature of this side chain affects: 1. the antimicrobial spectrum,

2. stability to stomach acid, 3. cross hypersensitivity, and 4. susceptibility to
bacterial degradative enzymes (β-lactamases).
A. Mechanism of action
 The penicillins interfere with the last step of bacterial cell wall synthesis
(transpeptidation or cross-linkage), resulting in exposure of the
osmotically less stable membrane. Cell lysis can then occur, either
through osmotic pressure or through the activation of autolysins.

Chapter 38 Structure of β-lactam antibiotics
Figure 38.2

II. Penicillins
A. Mechanism of action
 These drugs are bactericidal and work in a time-dependent fashion.
Penicillins are only effective against rapidly growing organisms that
synthesize a peptidoglycan cell wall.
 Consequently, they are inactive against organisms devoid of this

structure, such as mycobacteria, protozoa, fungi, and viruses.
1. Penicillin-binding proteins:
 Penicillins also inactivate numerous proteins on the bacterial cell
membrane. These penicillin-binding proteins (PBPs) are bacterial
enzymes involved in the synthesis of the cell wall and in the
maintenance of the morphologic features of the bacterium.
 Exposure to these antibiotics can therefore not only prevent cell wall
synthesis but also lead to morphologic changes or lysis of susceptible
bacteria.

II. Penicillins
1. Penicillin-binding proteins:
 The number of PBPs varies with the type of organism. Alterations in
some of these PBPs provide the organism with resistance to the
penicillins. [Note: Methicillin resistant Staphylococcus aureus (MRSA)
arose because of such an alteration.]
2. Inhibition of transpeptidase:
 Some PBPs catalyze formation of the cross-linkages between
peptidoglycan chains (Figure 38.3).
 Penicillins inhibit this transpeptidase-catalyzed reaction, thus hindering

the formation of cross-links essential for cell wall integrity.
3. Production of autolysins:
 Many bacteria, particularly the g+ve cocci, produce degradative
enzymes (autolysins) that participate in the normal re-modeling of the
bacterial cell wall.
Chapter 38 Bacterial cell wall of gram-positive bacteria
Figure 38.3
NAM = N acetylmuramic acid;

NAG = N-acetylglucosamine;
PEP = cross-linking peptide
II. Penicillins
3. Production of autolysins:
 In the presence of a penicillin, the degradative action of the autolysins
proceeds in the absence of cell wall synthesis. Thus, the antibacterial
effect of a penicillin is the result of both inhibition of cell wall synthesis
and destruction of the existing cell wall by autolysins.
B. Antibacterial spectrum
 In general, g+ve microorganisms have cell walls that are easily traversed
by penicillins, due to the fact that g+ve bacteria have proteins inserted
in the LPS layer that act as water-filled channels (called porins) to
permit transmembrane entry.
 G-ve m.o. have an outer LPS membrane surrounding the cell wall that
presents a barrier to the water-soluble penicillins.

II. Penicillins
1. Natural penicillins:
 Natural penicillins (penicillin G and penicillin V) are obtained from
fermentations of the fungus P. chrysogenum.
 Semisynthetic penicillins, such as amoxicillin and ampicillin (also known

as aminopenicillins), are created by chemically attaching different R
groups to the 6-aminopenicillanic acid nucleus.
 Penicillin G (benzyl-penicillin) is the cornerstone of therapy for

infections caused by a number of g+ve and g-ve cocci, g+ve bacilli, and
spirochetes (Figure 38.4).
 Penicillins are susceptible to inactivation by β-lactamases

(penicillinases) that are produced by the resistant bacteria.
 Penicillin remains the drug of choice for the treatment of gas gangrene
and syphilis.

Chapter 38 Typical therapeutic applications of penicillin G.
Figure 38.4

II. Penicillins
1. Natural penicillins:
 Penicillin V has a similar spectrum to that of penicillin G, but it is not
used for treatment of bacteremia because of its poor oral absorption.
2. Antistaphylococcal penicillins:
 Methicillin, nafcillin, oxacillin, and dicloxacillin are β-lactamase
(penicillinase)-resistant penicillins.
 Their use is restricted to the treatment of infections caused by

penicillinase-producing staphylococci, including methicillin sensitive
Staphylococcus aureus (MSSA).
 MRSA is currently a source of serious community and nosocomial

infections and is resistant to most commercially available β-lactam
antibiotics.
 The penicillinase-resistant penicillins have minimal to no activity against

g-ve infections.
II. Penicillins
3. Extended-spectrum penicillins:
 Ampicillin and amoxicillin have an antibacterial spectrum similar to that
of penicillin G but are more effective against g-ve bacilli (Figure 38.5A).
 These extended-spectrum agents are also widely used in the treatment

of RTI, and amoxicillin is employed prophylactically by dentists in high-
risk patients for the prevention of bacterial endocarditis.
 Resistance to these antibiotics is now a major clinical problem because

of inactivation by plasmid-mediated penicillinases.
 Formulation with a β-lactamase inhibitor, such as clavulanic acid or

sulbactam, protects amoxicillin or ampicillin, respectively, from
enzymatic hydrolysis and extends their antimicrobial spectra.
 For example, without the β-lactamase inhibitor, MSSA is resistant to

ampicillin and amoxicillin.

Chapter 38
Figure 38.5 Antimicrobial activity of ampicillin (A) and the antipseudomonal penicillins (B).

II. Penicillins
4. Antipseudomonal penicillins:
 Piperacillin and ticarcillin are called antipseudomonal penicillins
because of their activity against Pseudomonas aeruginosa (Figure
38.5B).
 These agents are available in parenteral formulations ONLY.
 Piperacillin is the most potent of these antibiotics.
 They are effective against many g-ve bacilli, but not against Klebsiella
because of its constitutive penicillinase.
 Formulation of ticarcillin or piperacillin with clavulanic acid or

tazobactam, respectively, extends the antimicrobial spectrum of these
antibiotics to include penicillinase-producing organisms (for example,
most Enterobacteriaceae and Bacteroides species).
 Figure 38.6 summarizes the stability of the penicillins to acid or the

action of penicillinase.
Chapter 38
Figure 38.6
Stability of the penicillins to

acid
or the action of penicillinase

II. Penicillins
C. Resistance:
1. β-Lactamase activity:
 This family of enzymes hydrolyzes the cyclic amide bond of the β-
lactam ring, which results in loss of bactericidal activity (Figure 38.2).
 They are the major cause of resistance to the penicillins and are an
increasing problem.
2. Decreased permeability to the drug:

 Decreased penetration of the antibiotic through the outer cell
membrane of the bacteria prevents the drug from reaching the target
PBPs.
3. Altered PBPs:
 Modified PBPs have a lower affinity for β-lactam antibiotics. This
explains MRSA resistance to most commercially available β-lactams.

II. Penicillins
D. Pharmacokinetics:
1. Administration:
 The route of administration of a β-lactam antibiotic is determined by
the stability of the drug to gastric acid and by the severity of the
infection.
a. Routes of administration:
 The combination of ampicillin with sulbactam, ticarcillin with clavulanic
acid, and piperacillin with tazobactam, and the antistaphylococcal
penicillins nafcillin and oxacillin must be administered IV or IM.
 Penicillin V, amoxicillin, and dicloxacillin are available ONLY as oral
preparations.
 Others are effective by the oral, IV, or IM routes (Figure 38.6).
b. Depot forms:
 Procaine penicillin G and benzathine penicillin G are administered IM
and serve as depot forms.

II. Penicillins
2. Absorption:
 Most of the penicillins are incompletely absorbed after oral
administration.
 Food ↓ the absorption of all the penicillinase-resistant penicillins
because as gastric emptying time ↑, the drugs are destroyed by
stomach acid→they should be taken on an empty stomach.
3. Distribution:
 The β-lactam antibiotics distribute well throughout the body. All the
penicillins cross the placental barrier, but none have been shown to
have teratogenic effects.
 Penetration into bone or cerebrospinal fluid (CSF) is insufficient for

therapy unless these sites are inflamed (Figures 38.7 and 38.8).
 Penicillin levels in the prostate are insufficient to be effective against

infections.
Chapter 38
Figure 38.7
Administration and fate of penicillin.

Chapter 38
Figure 38.8
Enhanced penetration of penicillin

into the cerebral spinal fluid (CSF)
during inflammation.

II. Penicillins
4. Metabolism:
 Host metabolism of the β-lactam antibiotics is usually insignificant, but
some metabolism of penicillin G may occur in patients with impaired
renal function.
5. Excretion:
 The primary route of excretion is through the organic acid (tubular)
secretory system of the kidney as well as by glomerular filtration.
 Patients with impaired renal function must have dosage regimens
adjusted.
 Nafcillin and oxacillin are exceptions to the rule. They are primarily
metabolized in the liver and do not require dose adjustment for renal
insufficiency.
 Probenecid ↓the secretion of penicillins by competing for active tubular
secretion via the organic acid transporter→↑blood levels.
 The penicillins are also excreted in breast milk.

II. Penicillins
E. Adverse reactions:
 Penicillins are among the safest drugs, and blood levels are not
monitored. However, adverse reactions may occur (Figure 38.9).
1. Hypersensitivity:
 Approximately 5% percent of patients have some kind of reaction,
ranging from rashes to angioedema and anaphylaxis.
 Cross-allergic reactions occur among the β-lactam antibiotics.
2. Diarrhea:
 Diarrhea is a common problem that is caused by a disruption of the
normal balance of intestinal microorganisms.
3. Nephritis:
 Penicillins, particularly methicillin, have the potential to cause acute
interstitial nephritis. Methicillin is no longer used clinically.

II. Penicillins
E. Adverse reactions:
4. Neurotoxicity:
 The penicillins are irritating to neuronal tissue, and they can provoke
seizures if injected intrathecally or if very high blood levels are reached.
 Epileptic patients are particularly at risk due to the ability of penicillins

to cause GABAergic inhibition.
5. Hematologic toxicities:
 Decreased coagulation may be observed with high doses of piperacillin,
ticarcillin, and nafcillin (and, to some extent, with penicillin G).
 Cytopenias have been associated with therapy of greater than 2 weeks,

and therefore, blood counts should be monitored weekly for such
patients.

III. Cephalosporins
 The cephalosporins are β-lactam antibiotics that are closely related
both structurally and functionally to the penicillins.
 Most cephalosporins are produced semi-synthetically by the chemical

attachment of side chains to 7-aminocephalosporanic acid.
 Cephalosporins have the same mode of action as penicillins, and they

are affected by the same resistance mechanisms. However, they tend to
be more resistant than the penicillins to certain β-lactamases.
A. Antibacterial spectrum
1. First generation:
 The first-generation cephalosporins act as penicillin G substitutes.
2. Second generation:
 The second-generation cephalosporins display greater activity against
three additional g-ve organisms, whereas activity against g+ve
organisms is weaker.
III. Cephalosporins
2. Second generation:
 Antimicrobial coverage of the cephamycins (cefotetan and cefoxitin)
also includes anaerobes. They are the only cephalosporins
commercially available with appreciable activity against g-ve anaerobic
bacteria. However, neither drug is first line because of the increasing
prevalence of resistance to both agents.
3. Third generation:
 The third-generation cephalosporins have enhanced activity against g-
ve bacilli, as well as most other enteric organisms.
 Ceftriaxone & cefotaxime have become agents of choice in the

treatment of meningitis.
 Ceftazidime has activity against P. aeruginosa; resistance is ↑ & use

should be evaluated on a case-by-case basis.

III. Cephalosporins
3. Third generation:
 Third-generation cephalosporins must be used with caution, as they are
associated with significant “collateral damage,” essentially meaning the
induction and spread of antimicrobial resistance. [Note:
Fluoroquinolone use is also associated with collateral damage.]
4. Fourth generation:
 Cefepime is administered parenterally.
 Cefepime has a wide antibacterial spectrum and is also effective against
aerobic g-ve organisms.
5. Advanced generation:
 Ceftaroline is a broadspectrum, that is administered IV as a prodrug,
ceftaroline fosamil.
 It is the only commercially available β-lactam in the US with activity
against MRSA and is indicated for the treatment of complicated skin
and skin structure infections and community-acquired pneumonia.
III. Cephalosporins
5. Advanced generation:
 The unique structure allows ceftaroline to bind to PBP2a found with
MRSA and PBP2x found with Streptococcus pneumoniae. In addition to
its broad g+ve activity, it also has similar g-ve activity to the third-
generation cephalosporin ceftriaxone.
 Important gaps in coverage include P. aeruginosa, extendedspectrum β-
lactamase (ESBL)-producing Enterobacteriaceae, and Acinetobacter
baumannii. The twice-daily dosing regimen also limits use outside of an
institutional setting.
B. Resistance
 Mechanisms of bacterial resistance to the cephalosporins are
essentially the same as those described for the penicillins.

III. Cephalosporins
C. Pharmacokinetics
1. Administration:
 Many of the cephalosporins must be administered IV or IM (Figure
38.11) because of their poor oral absorption.
 Exceptions are noted in Figure 38.12.
2. Distribution:
 All cephalosporins distribute very well into body fluids. Adequate
therapeutic levels in the CSF, regardless of inflammation, are achieved
with only a few cephalosporins.
 For example, ceftriaxone and cefotaxime are effective in the treatment
of neonatal and childhood meningitis caused by H. influenzae.
 Cefazolin is commonly used as a single prophylaxis dose prior to surgery
because of its 1.8-hour half-life and its activity against penicillinase-
producing S. aureus. Cefazolin is effective for most surgical procedures,
including orthopedic surgery because of its ability to penetrate bone.
 All cephalosporins cross the placenta.

Chapter 38
Figure 38.11
Administration and fate of

the cephalosporins.

Chapter 38
Figure 38.12

III. Cephalosporins
C. Pharmacokinetics
3. Elimination:
 Cephalosporins are eliminated through tubular secretion and/or
glomerular filtration (Figure 38.11).
 Therefore, doses must be adjusted in cases of renal dysfunction to
guard against accumulation and toxicity.
 One exception is ceftriaxone, which is excreted through the bile into the
feces and, therefore, is frequently employed in patients with renal
insufficiency.
D. Adverse effects
 Like the penicillins, the cephalosporins are generally well tolerated.
 However, allergic reactions are a concern. Patients who have had an
anaphylactic response, Stevens-Johnson syndrome, or toxic epidermal
necrolysis to penicillins should not receive cephalosporins.
 Cephalosporins should be avoided or used with caution in individuals
with penicillin allergy.

III. Cephalosporins
C. Pharmacokinetics
D. Adverse effects
 Current data suggest that the cross-reactivity between penicillin and
cephalosporins is around 3% to 5% and is determined by the similarity
in the side chain, not the β-lactam structure.
 The highest rate of allergic cross-sensitivity is between penicillin and

first-generation cephalosporins.

IV. Other β-lactam antibiotics
A. Carbapenems
 Carbapenems are synthetic β-lactam antibiotics that differ in structure
from the penicillins in that the sulfur atom of the thiazolidine ring
(Figure 38.2) has been externalized and replaced by a carbon atom
(Figure 38.13).
 Imipenem, meropenem, doripenem, and ertapenem are the drugs of

this group currently available.
 Imipenem is compounded with cilastatin to protect it from metabolism

by renal dehydropeptidase.
B. Monobactams
 The monobactams, which also disrupt bacterial cell wall synthesis, are
unique because the β-lactam ring is not fused to another ring (Figure
38.13).

Chapter 38 Figure 38.13

IV. Other β-lactam antibiotics
B. Monobactams
 Aztreonam, which is the only commercially available monobactam, has
antimicrobial activity directed primarily against g-ve pathogens,
including the Enterobacteriaceae and P. aeruginosa. It lacks activity
against g+ve organisms and anaerobes.
 Aztreonam is resistant to the action of most β-lactamases, with the

exception of the ESBLs.
 It is administered either IV or IM and can accumulate in patients with

renal failure. Aztreonam is relatively nontoxic, but it may cause
phlebitis, skinmrash and, occasionally, abnormal liver function tests.
 This drug has a low immunogenic potential, and it shows little cross-
reactivity with antibodies induced by other β-lactams. Thus, this drug
may offer a safe alternative for treating patients who are allergic to
other penicillins, cephalosporins, or carbapenems.

V. β-lactamase inhibitors
 Hydrolysis of the β-lactam ring, either by enzymatic cleavage with a β-
lactamase or by acid, destroys the antimicrobial activity of a β-lactam
antibiotic.
 β-Lactamase inhibitors, such as clavulanic acid, sulbactam, and

tazobactam, contain a β-lactam ring but, by themselves, do not have
significant antibacterial activity or cause any significant adverse effects.
 Instead, they bind to and inactivate β-lactamases, thereby protecting

the antibiotics that are normally substrates for these enzymes.
 The β-lactamase inhibitors are therefore formulated in combination

with β-lactamase–sensitive antibiotics. For example, Figure 38.15.

Chapter 38
The in vitro growth of Escherichia coli in the presence of amoxicillin, with and without clavulanic acid
Figure 38.15

Others
VI. Vancomycin
VII. Daptomycin
VIII. Telavancin
See figure 38.18 in book for side-by-side comparison of the three

antibiotics
IX. Fosfomycin
X. Polymyxins

Chapter 38
Figure 38.18

Chapter 38
Figure 38.18


O U
Y
NK
H A
T

Cell Wall Inhibitors: Zarqa University Pharmacy School Clinical Pharmacy and Therapeutics Department Pharmacology III

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cell Wall Inhibitors: Zarqa University Pharmacy School Clinical Pharmacy and Therapeutics Department Pharmacology III

Uploaded by

Copyright:

Available Formats

Zarqa University

Cell Wall Inhibitors

Dr. Fares Al Bahar

 To be able to discuss some antimicrobial drugs selectivity

 To be able to understand the most important members of cell

 To be able to understand the mechanism of action, antibacterial

Cell Wall Inhibitors 2

 Some antimicrobial drugs selectively interfere with synthesis of the

 The cell wall is composed of a polymer called peptidoglycan that

 To be maximally effective, inhibitors of cell wall synthesis require

 Figure 38.1 shows the classification of agents affecting cell wall

Cell Wall Inhibitors 4

Copyright © 2015 Wolters Kluwer • All Rights Reserved

Copyright © 2015 Wolters Kluwer • All Rights Reserved

 The nature of this side chain affects: 1. the antimicrobial spectrum,

Cell Wall Inhibitors 7

Copyright © 2015 Wolters Kluwer • All Rights Reserved

 Consequently, they are inactive against organisms devoid of this

Cell Wall Inhibitors 9

 Penicillins inhibit this transpeptidase-catalyzed reaction, thus hindering

NAM = N acetylmuramic acid;

Cell Wall Inhibitors 12

 Semisynthetic penicillins, such as amoxicillin and ampicillin (also known

 Penicillin G (benzyl-penicillin) is the cornerstone of therapy for

 Penicillins are susceptible to inactivation by β-lactamases

Cell Wall Inhibitors 13

Copyright © 2015 Wolters Kluwer • All Rights Reserved

 Their use is restricted to the treatment of infections caused by

 MRSA is currently a source of serious community and nosocomial

 The penicillinase-resistant penicillins have minimal to no activity against

 These extended-spectrum agents are also widely used in the treatment

 Resistance to these antibiotics is now a major clinical problem because

 Formulation with a β-lactamase inhibitor, such as clavulanic acid or

 For example, without the β-lactamase inhibitor, MSSA is resistant to

Cell Wall Inhibitors 16

Copyright © 2015 Wolters Kluwer • All Rights Reserved

 Piperacillin is the most potent of these antibiotics.

 Formulation of ticarcillin or piperacillin with clavulanic acid or

 Figure 38.6 summarizes the stability of the penicillins to acid or the

Stability of the penicillins to

Copyright © 2015 Wolters Kluwer • All Rights Reserved

2. Decreased permeability to the drug:

Cell Wall Inhibitors 20

Cell Wall Inhibitors 21

 Penetration into bone or cerebrospinal fluid (CSF) is insufficient for

 Penicillin levels in the prostate are insufficient to be effective against

Administration and fate of penicillin.

Copyright © 2015 Wolters Kluwer • All Rights Reserved

Enhanced penetration of penicillin

Copyright © 2015 Wolters Kluwer • All Rights Reserved

Cell Wall Inhibitors 25

Cell Wall Inhibitors 26

 Epileptic patients are particularly at risk due to the ability of penicillins

 Cytopenias have been associated with therapy of greater than 2 weeks,

Cell Wall Inhibitors 27

 Most cephalosporins are produced semi-synthetically by the chemical

 Cephalosporins have the same mode of action as penicillins, and they

 Ceftriaxone & cefotaxime have become agents of choice in the

 Ceftazidime has activity against P. aeruginosa; resistance is ↑ & use

Cell Wall Inhibitors 29

Cell Wall Inhibitors 31

Cell Wall Inhibitors 32

Administration and fate of