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Beta Lactam Compounds
Beta Lactam Compounds
Moises Jaime A. Jamila Jr., RPh University of Immaculate Conception MS Pharmacy class 24 July 2010
PENICILLINS
Chemistry
A) B)
6-aminopenicillanic acid nucleus (A+B) - essential for the biologic activity of these compounds
beta-lactamase
Beta-lactam ring
penicilloic acid
(no antibacterial activity)
3 Basic Groups:
Penicillins y Antistaphylococcal Penicillins
y
Nafcillin
y
Extended-Spectrum Penicillins
Ampicillin
Penicillin (Pen G)
y
Staphylococci Streptococci
y
Possess the antibacterial spectrum of penicillins + an improved activity against gram (-) organisms Hydrolyzed by beta-lactamases
Pen G K
: 1.7 mEq of K / M units (2.8 mEq/g) Nafcillin Na : 2.8 mEq/g Procaine and Benzathine salts
- Provide repository forms for IM injections
*minimum
inhibitory concentration
Stability
Dry crystalline form
stable for years at 4oC
Solution
stable for 24 hours at 20oC freshly prepared
Mechanism of Action
-
Resistance
1. 2. 3. 4.
Inactivation of antibiotic by betalactamase Modification of transport PBPs* Impaired penetration of drug to target PBPs Efflux
*penicillin-binding protein(s)
Penicillins
S. aureus, Haemophilus sp & E. coli
Carbapenems
Metallo -lactamases & carbapenemases
*extended spectrum -lactamases
Methicillin-resistance
Staphylococci
Penicillin resistance
Pneumococci & Enterococci
- Organisms produce PBPs that have low affinity for binding -lactam antibiotics, and consequently they are not inhibited except at high, often clinically unachievable drug concentrations.
G(-) species
- Impermeable outer cell wall membrane w/c is absent in G(+) species - B-lactam antibiotics cross the outer membrane & enter G(-) organisms via outer membrane protein channels (porins) - B-lactamase: may hydrolyze drug faster than it enters the cell.
4. Efflux
y
G(-) organisms
- May produce an efflux pump (cytoplasmic and periplasmic protein components)
PHARMACOKINETICS
Absorption
y
Administration
y
IV is preferred to the IM route because of irritation and local pain from IM inj of large doses.
Distribution
y
Polar
- intracellular conc are low than those found in extracellular fluids 1g Pen G IV: 20-50 mcg/mL serum conc Nafcillin : highly protein-bound Pen G & Ampicillin : less protein-bound
Distribution
Benzathine and Procaine
- Formulated to delay absorption
1.2 M u IM inj of Benzathine Penicillin : 0.02 mcg/mL serum conc 10 days : hemolytic streptococcal infection 600, 000 u IM inj of Procaine Penicillin : 1-2 mcg/mL serum conc for 12-24 hours
Distribution
Tissue Conc = Serum Conc Eye, Prostate & CNS: poor penetration Bacterial Meningitis
18-24 M u daily dose of Penicillin will yield 15 mcg/mL serum conc, sufficient to kill strains of pneumococci & meningococci
Half - Life
Penicillin - t : 30 minutes; 10 hours (renal failure) Ampicillin & Extended-Spectrum Penicillins - t : 1 hour
Excretion
Renal Excretion
10% glomerular filtration 90% tubular secretion
(140 - age ) x BW (kg) x *F ------------------------------------Serum creatinine (mmol/L) x 815 *F = (multiply by) 1 if male, and 0.85 if female
CLINICAL USE
Probenecid - Increases blood levels of Penicillin - Impairs renal tubular secretion of weak acids (B-lactam cmpds) - 0.5 g (10 mg/kg in children) q6o PO
Penicillin G
DOC
-
streptococci, meningococci, enterococci, penicillinsusceptible pneumococci, non-lactamase producing staphylococci,T. pallidum & other spirochetes, clostridium spp, actinomyces, & other G(+) rods & non B-lactamase producing G(-) anaerobic orgs.
Dose
-
Penicillin V
Oral form of penicillin y Indicated for minor infections y Poor bioavailability y QID dosing y Narrow antibacterial spectrum
y
1.2 M u IM q 3-4 wks B-hemolytic streptococcal pharyngitis 2.4 M u IM once a week for 1-3 wks (syphilis)
Oxacillin, Cloxacillin & Dicloxacillin (Isoxazolyl) 0.25-0.5 g orally q4-6o 15-25 mg/kg/day for children Acid-stable Given 1 hr before or after meals
Ampicillin
effective for shigellosis
Cephalosporins
y
4 Generations
y
First Generation have better activity against G(+) organisms and the later Generations exhibit improve activity against G(-) aerobic organisms.
Monobactams
Monocyclic B-lactam ring y Relatively resistant to B-lactamase and active against G(-) rods (pseudomonas & serratia) Aztreonam
y Resembles aminoglycosides (spectrum of activity) - 1-2g IV q8o - t : 1-2 hrs; prolonged in renal failure - Penicillin allergic Px tolerate Aztreonam w/o reaction
-
BetaBeta-lactamase inhibitors:
Clavulanic Acid, Sulbactam & Tazobactam
Resembles B-lactam molecules; have weak antibacterial action. y Active against class A:
y
staphylococci, H. influenzae, N. gonorrheae, salmonella, shigella, E. coli, & K. Pneumoniae
BetaBeta-lactamase inhibitors
Available in fixed combination w/ specific penicillins. y An inhibition will extend the spectrum of a penicillin provided that the inactivity of the penicillin is due to the destruction by Blactamases and that the inhibition is active against the B-lactamase produced
y
Ampi+Sulbactam: active against S aureus & H influenzae but not against serratia
y
Carbapenems
(Imipenem, Meropenem & Ertapenem) Imipenem, Ertapenem) Imipenem
inactivated by dehydropeptase in renal tubules Administered w/ cilastatin (renal dehydrogenase inhibitor) Penetrate CSF
Carbapenems
y
The B-lactam antibiotic of choice for the treatment of enterobacter infections. Dose: Imipenem: 0.25-0.5g IV q6-8o (t: 1 hr) Meropenem: 1g IV q8o Ertapenem: 1g q24o IV or IM (t: 4 hrs) : 1% lidocaine for IM
Carbapenems
ADR: Imipenem
N/V, diarrhea, skin rashes Excessive levels of imipenem in Px w/ RF may lead to seizures
Vancomycin
y y y y
Produced by Streptococcus orientalis Active only against G(+) bacteria (staphylococcus) Poorly absorbed from the GIT Not removed by hemodialysis MOA:
inhibit cell wall synthesis
Indication:
Sepsis and endocarditis
Resistance:
Due to modification of the D-ala-D-ala binding site, terminal D-ala is replaced by D-lactate
Vancomycin + Gentamicin
y
Vancomycin +
Cefotaxime / Ceftriaxone / Rifampicin
Treatment of meningitis suspected or caused by highly penicillin-resistant strain of pneumococcus. Dose: A: 30mg/kg/d 2-3 div doses; 1g q12o P: 40mg/kg/d 3-4 div doses Renal Px: 1g every week PO: 0.125 0.25g q6o : Tx antibiotic-associated enterocolitis : vanco-resistant enterococci: metronidazole initial therapy
y
Vancomycin
ADR: Phlebitis at the site of inj, chills, fever Red man or red neck syndrome:
infusion related flushing (caused by the release of H1 Prevented by prolonging infusion period to 1-2 hrs or by increasing the dosing interval.
Teicoplanin
IM or IV y t: 45-70 hours; OD dosing y Similar to Vancomycin MOA
y
Fosfomycin
MOA:
Inhibits cytoplasmic enzyme enolpyruvate transferase (early stage of bacterial cell wall synthesis)
Resistance:
Inadequate transport of drug into the cell.
Susceptibility test:
Growth medium w/ glucose 6-phosphate.
Indication:
Single 3g dose: Tx uncomplicated UTI in women. Safe in pregnancy. G(+) & G(-) t : 4 hours
Bacitracin
y y y y
Obtained from Bacillus subtilis Nephrotoxic, limited to topical use; poorly absorbed Combined with polymyxin & neomycin Soln of 100-200 u/mL in saline: irrigation ( joints, wounds or pleural cavity) Inhibit cell wall formation by interfering w/ dephosphorylation in cycling of the lipid carrier that transfers peptidoglycan to the growing cell wall.
MOA:
Cycloserine
y y y
Produced by Streptomyces orchidaceus Water soluble and very unstable to acid pH Inhibits G(+) & G(-), used almost exclusively to treat TB Structural analog of D-alanine & inhibits the incorporation of D-alanine
MOA: Dose:
0.5-1g/d in 2-3 divided doses
ADR:
Headache, tremors, acute psychosis & convulsions (dose: < 0.75 g/d)
G(+)
G(-) cocci / x
G(-) rods L x G
Entero -cocci
Staph
Strep
Anaerobic
Beta
Lactamase resistant
Penicillin Nafcillin Ampillin Monobactam Imipenem Meropenem Ertapenem Vancomycin Fosfomycin Cycloserine
/ x / L
/ / / /
thank you
-moe