Chemotherapy:

Chemotherapy may be defined as the branch of

pharmacology that deals with effects of drugs on
microorganisms and parasites that are multiplying
in the patient’s tissues. Such substances include
natural or synthetic compounds which selectively
kill the microorganisms or inhibit their growth
without causing any injury or damage to host. The
term chemotherapy is also, now-a-days, applied to
the use of chemicals (either natural, semi- synthetic
or synthetic) used to inhibit the growth of
malignant or cancerous cells in the body.
Pharmacotherapeutics:
It is the application of drugs in the diagnosis
prevention and treatment of diseases and their use
in purposeful alteration of normal functions, such as
in prevention of pregnancy or in the use of
anaesthetics for surgical procedures.
Pharmacotherapetuics is of primary concern to
those who are engaged in healing professions. It is
the branch of pharmacology which correlates
pharmacodynamics with the pathologic physiology
or microbiologic or biochemical aspects of disease.
 Fig:-
Pharmacology today with its various subdivisions,
interface disciplines (brown boxes) link pharmacology
to other mainstream disciplines (green boxes).
 DEFINITION
: OF ANTIBIOTIC

Old Definition:
Antibiotics are compounds that are produced by
various species of microorganisms (bacteria,
fungi, actinomycetes) and have the capability to
either kill or inhibit the growth of other
microorganisms. This definition makes a
distinction between antimicrobials produced by
microorganisms and those that are totally
synthetic.
This definition is rather academic, and the word
antibiotic, now-a-days, is often used to include all
three groups i.e. synthetic semi-synthetic and
obtained from microorganisms.
Antibiotics are compounds of natural, semi-
synthetic, synthetic or microbial origin that have
the capability to either kill or inhibit the growth of
microorganisms. Now-a-days, antibiotics are also
used to treat malignant tumours. An ideal
antimicrobial exhibits selective toxicity meaning
by that the drug is harmful to a parasite without
causing any harmful effect to the host.
Antibacterials may be:
i- Bacteriostatic
ii- Bactericidal
Bacteriostatic:
Bacteriostatic drugs inhibit the growth of
microorganisms temporarily. The therapeutic
success of these agents depends on the
participation of defense mechanisms of the host.
The effect may be reversible. When the drug use
is stopped, the organism will resume growth and
infection or disease will reoccur in immuno-
compromised patients.
Bacteriostatic drugs are tetracyclines,
sulphonamides, chloramphenicol, erythromycine
etc.
The term bactericidal is applied to describe those
agents which kill the microorganisms. Examples
of such drugs are penicillins, cephalosporins and
aminoglycosides. The treatment with bactericidal
drugs becomes mandatory in case of those
infections that cannot be controlled or eradicated
by defence mechanisms of host e.g. infective
endocarditis and other endovascular infections,
meningitis and infections in neutropenic cancer
patients.
However, the terms bactericidal and bacteriostatic
are relative and not absolute. As sometime
prolonged treatment with or higher dose of
bacteriostatic can cause death of microbial
population (e.g. chloramphenicol in case of
meningococci), while bactericidal drugs may fail
to kill the microbes (e.g. pencilline G in case of
enterococci).
 SUSCEPTIBILITY AND RESISTANCE OF
MICROORGANISMS TO ANTIMICROBIALS

Achieving a concentration of antibiotic at the site

of infection that is sufficient to inhibit bacterial
growth is the most important factor among
several others that contribute towards
therapeutic success.
Definition of Susceptibility:
If the dose or concentration of drug produces the
desired necessary effect on the microorganisms
without being toxic to human cells, the micro-
organisms are said to be sensitive to the drug.
Definition of Resistance:
On the other hand if the concentration of a drug
required to inhibit or kill the microorganisms is
greater than the concentration that can be safely
achieved, the microorganism is considered to be
resistant to the antibiotic. Most in-vitro sensitivity
tests are standardized on the basis of drug
concentration, that can be safely achieved in
plasma. They do not reflect concentrations that can
be achieved at the sites of infections, nor they take
into account the local factors that might affect the
activity of drug. Thus in-vitro tests have their
limitations.
For example gram-negative bacilli, Pseudomonas
aeruginosa, are inhibited by 2-4µg/ml of
gentamycin or tobramycin, so these are said to be
sensitive to these drugs. However, the sustained
concentrations in plasma above 6-10 µg/ml may
cause oto- or nephro-toxicity. Also concentrations
of these drugs at certain sites of infection (such as
vitreous fluid or cerebrospinal fluid) may be much
lower than those in plasma.
 Thus these drugs may be only marginally effective
or ineffective in such case even though
standardized in-vitro tests would report the
microorganisms sensitive.
Conversely, the conc. of drug in urine may be
much higher than plasma. Thus microorganisms
reported as resistant may respond to therapy
when infection is restricted to urinary tract only.
There are two methods most widely used for in
vitro sensitivity testing. They are:
i- Disk diffusion
ii- Broth dilution
In disk diffusion method, paper disks
impregnated with known amounts of
antimicrobials are placed on the surface of an
agar plate that has been streaked with a standard
inoculum of the microorganisms. Then after an
appropriate incubation period (18-24 hrs) at
suitable temperature, depending on the type of
microorganism, the diameters of clear zones
around the disks indicating no microbial growth
are measured.
These diameters are interpreted as susceptible,
intermediate or resistant for individual drugs by
referring to standardized values. This provides
qualitative or semi-quantitative data on inhibiting
activity of an agent. Now-a-days Well Method is
being used by researchers for screening the
compounds for their antimicrobial activities.

Broth-Dilution method is used to determine the

quantitative susceptibility of an organism to an
antimicrobial agent.
 In this method serial two-fold dilutions of
antibiotic in broth are inoculated with a
standardized suspension of microorganisms.
For bacteria, after an overnight incubation the
results are expressed as under:
a) MIC (Minimum Inhibitory Concentration):
It is the lowest concentration of the drug that
inhibits visible growth after an overnight
incubation or suitable incubation period
depending upon species of microbe.
b) MBC (Minimum Bactericidal Concentration):
This can be determined by subculturing tubes that
show no bacterial growth onto agar plates and re-
incubating overnight. It is the lowest
concentration of the drug that kills at least 99.9 %
of original bacterial inoculum. The results of MIC
and MBC should be correlated with
concentrations of drugs achieved in plasma and
other body fluids and tissues.
IMPORTANT NOTE:

For drugs, which are primarily bacteriostatic,

MICs are much lower than MBCs. In
comparison, primarily bactericidal drugs
demonstrate little difference between MICs
and MBCs.
 Bactericidal drugs can be subdivided into two
groups:
I- Drug that exhibit concentration-dependent killing
e.g. aminoglycosides and quinolones.
II- Drug that exhibit time-dependent killing (e.g.
beta lactam and vacncomycin).
For bactericidal drugs whose killing action is
concentration –dependent, the rate and extent of
killing increases with increasing drug
concentrations above MBC without exceeding
MTC. Maximizing peak serum concentrations of
these drugs results in increased efficacy and
decreased selection of resistant bacteria.
Concentration-dependent killing is one of the
pharmacodynamic factors responsible for the
efficacy of once-daily dosing of aminoglycosides.
Also, aminoglycosides possess significant
postantibiotic effect.
Drug whose bactericidal action is time dependent
do not exhibit increased killing with increasing
concentration above MBC; bactericidal activity
continues as long as serum drug concentrations
are greater than MBC.
 In other words, bactericidal activity is directly
related to the time above MBC and becomes
independent of concentration once MBC is
exceeded. Drug serum concentration of time-
dependent killing agents that lack post-antibiotic
effect should be maintained above MBC for entire
dosage interval.
Postantibiotic Effect (PAE) :
Refers to persistent suppression of bacterial
growth even when plasma levels are below MBC,
after limited exposure to an antimicrobial agent.
PAE infact reflects the time required for bacteria
to return to logarithmic growth.
Most antimicrobials have significant in-vitro (> 1.5 hrs)
against susceptible gram-positive cocci; whereas
only a few antimicrobials (carbapenems,
chloromphenicol, aminoglycosides, quinolones,
rifampin & tetracyclines) possess PAEs against
susceptible gram negative bacilli. The in vivo PAEs
are usually much longer than in vitro. This is
thought to be due to Postanitibiotic Leukocyte
Enhancement (PALE) and exposure of bacteria to
subinhibitory antibiotic concentrations.
PALE reflects the increased susceptibility of bacteria
to phagocytic and bactericidal actions of
neutrophils.
The sub-inhibitory drug concentrations result in
changed bacterial morphology and decreased rate
of growth.
PAE = T- C
T is time required for the viable count in test culture
(in-vitro) to increase ten fold above the count
observed immediately before drug removal and C
represents time required for the count in an
untreated culture to increase ten fold above the
count observed immediately after completion of
the same procedure used on the test culture.
 SELECTION OF ANTIMICROBIAL AGENT TO
TREAT INFECTIOUS DISEASES
Generally, antibiotics are used in two ways:
i- As Empirical Therapy or Initial Therapy
ii- As Definitive Therapy
EMPIRICAL THERAPY:
Ideally, the selection of the antibiotic should be
made after the proper identification of the
infecting microorganism and establishing its
sensitivity. However, in critically ill patients such
delay might prove fatal.
Thus in such cases empirical therapy becomes
inevitable. It means therapy with antibiotic is
started prior to the identification of
microorganism and its sensitivity testing. For
example, a meningitis case needs immediate
treatment and delay may result in death of the
patient. Initiation of optimal empirical antibiotic
therapy requires knowledge of most likely
infecting microorganisms and their susceptibilities
to antimicrobials. Clinical picture of the patient
helps the therapist to know the microorganism
most likely to cause specific infection in a given
host.
Gram’s staining, a fast bacterial identification test,
can be of much help in narrowing the list of
potential pathogens and permit more rational start
of antibiotic therapy. However, in most cases, only
identification of morphology of the infecting
organism is not enough to reach the specific
bacteriological diagnosis and the selection of a
single narrow-spectrum antibiotic may be
inappropriate, especially when the disease is life
threatening. Thus a broad antimicrobial coverage
i.e. a combination of antibiotics or a broad
spectrum agent covering infection from both
 G +ive and G -ive microorganisms should be
initiated. The following extremely important
precaution must not be missed before starting
therapy. “Whenever the clinician is faced with
initiating therapy on a presumptive bacteriological
diagnosis, cultures of blood and certain other body
fluids/tissues should be taken prior to the
institution of drug therapy.”

DEFINTIVE THERAPY:
Once the infecting microorganism is identified and
its susceptibility established, definitive therapy
should be instituted to replace the empirical
therapy.
 For definitive therapy the regimen should be
changed to more specific (i.e. narrow spectrum)
antimicrobial agent having low toxicity. To make
the selection of most appropriate antimicrobial
agent, the following factors must be taken into
account.
1- PHARMACOKINETIC FACTORS:
Although the knowledge of in vitro sensitivity
tests helps to a great extent in selecting the
antibiotic but it is not the only factor to be
considered. Actually success of therapy depends
upon achieving the minimal drug concentration
approximately equal to MIC at the site of
infection without causing significant toxicity to
the host. However, there is evidence to suggest
that even sub-inhibitory drug concentrations are
effective because of enhancing the process of
phagocytosis. Although such observations may
explain why some infections are cured even
when inhibitory concentrations are not
achieved, it should be the objective of
antimicrobial therapy to maintain the
antimicrobial concentrations of drug at the site
of action during dosing interval.
 This can be achieved only by fully understanding
and following the principles of P. Kinetics and P.
Dynamics.
2- EFFECT OF SITE OF INFECTION ON THERAPY:
Adequate levels of an antibiotic must reach the
site of infection in order to eradicate the
microorganisms effectively. Natural Barriers
may hamper the penetration of the drug into
certain tissues. The examples of such situations
are as under:
Blood-Brain Barrier (BBB):
If the infection is in the CSF, the drug must pass
the BBB. Many antibiotics are polar at
physiological pH and can cross the BBB very
poorly. The concentrations of penicillins and
cephalosporins in the CSF are only 0.5-5% of
plasma steady state concentrations. However,
the integrity of BBB is diminished in the
inflammatory conditions due to active bacterial
infection. This change (tight junctions in
cerebral capillaries open) leads to a marked
increase in penetration of even polar drugs into
CSF. As the condition improves, inflammation
 diminishes and permeability returns to normal.
This may occur in the presence of some viable
microorganisms in the CSF, thus drug dosage
should not be reduced till the CSF is presumed or
proved to be sterile.
b) Plasma-Protein Binding:
Almost, in majority of cases, penetration of drugs
into infected loci always depends on passive
diffusion. The rate of diffusion is proportional to
the concentration of free drug (unbound) in the
plasma/extracellular fluid. Thus drugs extensively
bound to plasma proteins may penetrate poorly
 as compared to unbound drugs, consequently
highly plasma protein bound drugs may have
lesser or reduced activity.
Prostrate Infection:
Bacterial prostatitis is difficult to cure because
many antibiotics fail to cross the prostatic
epithelium and do not reach the prostatic fluid
and tissue. Moreover, the pH of prostatic fluid is
6.4 (acidic) compared to plasma (7.4).
Trimethoprim (basic antimicrobial) is effective in
treating prostatitis.
d) Maintenance of MIC at the Site of Infection:
It sounds reasonable that an attempt be made to
achieve antibacterial activity at the site of
infection during the dosing interval. However,
controversy exists whether the therapeutic effect
obtained from relatively constant antibacterial
activity is superior to that obtained from high
peak concentrations followed by periods of
sub-inhibitory activity. To some extent, it
depends upon whether the antimicrobial agent
exhibits concentration-dependent or time
dependent growth inhibition.
For example, the activity of β-lactam antibiotics is
time-dependent whereas that of aminoglycosides
is concentration dependent. Studies in animals
with meningitis suggest that pulse dosing
(intermittent dosing) with β-lactam antibiotics is
more efficacious (equivalent efficacy from less
drug). On the other hand experimental data
suggest that aminoglycosides are at least as
efficacious, and are less toxic, when given in a
single large daily dose in comparison to when
given more frequently.
 Clinical studies have also shown that continuous
administration of aminoglycosides may cause
unnecessary toxicity. The knowledge of status of
individual patient and mechanism of elimination
of drugs is essential in case of drugs causing
serious toxicity. The doses of drugs should be
carefully adjusted in patients with impaired renal
and/or hepatic functioning.
3 ROUTE OF ADMINISTRATION:
Whenever possible oral administration is
preferred. However, in seriously ill patient
 parenteral administration becomes necessary to
achieve therapeutic plasma level without delay.
For obtaining maximal therapeutic effectiveness,
all the factors governing the choice of route of
administration for individual drug be followed
strictly.
4- HOST FACTORS: (Status of the patient)
Innate host factors which apparently seem not to
be related to infection being treated, are prime
determinants of type of antimicrobial, its dose
regimen and toxicity and expected effectiveness.
Such factors are as under:
a) Renal Dysfunction:
Impairment of renal function may lead to the
accumulation of those antibiotics which are
mainly eliminated by kidneys. This may result
into serious side-effects if appropriate dose
adjustments are not made. Care must be taken
in case of using aminoglycosides, vancomycin or
flucytosine in patients with renal impairment
because these drugs are exclusively eliminated
by renal mechanisms. The number of functional
nephrons decreases with age and as a result of it
elderly people are specially vulnerable
 to accumulation of drugs eliminated by kidneys.
b) Hepatic Dysfunction:
For drugs that are concentrated, metabolized or
excreted by the liver (erythromycin,
chloramphenicol, metronidazole, tetracyclines),
dose must be reduced in patients with hepatic
failure or dysfunctioning. In liver cirrhosis the
half-lives of rifampin and isoniazid are prolonged.
Infection of biliary tract or biliary obstruction may
cause reduced access of drug to the site of
infection (ampicillin).
c) Age:
Hepatic metabolism and renal excretion
mechanisms are poorly developed in new borns
especially the premature infants. Improper
adjustment in dose in such cases may lead to
serious consequences e.g. gray baby syndrome.
Elderly people are also prone to toxic effects of
drugs that are eliminated by hepatic or renal
mechanisms since these mechanisms are less
functional as compared to the adult age.
Developmental factors are also primary
determinants of type of antibiotic used.
 As tetracyclines bind Rapidly to developing teeth
and bones, their use in children can lead to
retardation of bone growth and discolouration or
hypoplasia of tooth enamel. Similarly,
fluoroquinolones can accumulate in cartilage of
growing bone and my retard the growth of
cartilage. Achlorhydria in young children and
elderly patients may alter the absorption of orally
administered antibiotics (increased absorption of
penicillin G whereas decreased absorption of
ketoconazole)
d) Pregnancy:
Antibiotics easily cross placental barrier and affect
the foetus.
Phocomelia
 For example hearing loss in the child may be
associated with streptomycin therapy to the
mother during pregnancy. Tetracycline
administration to pregnant females can affect the
growth of bones and teeth of foetus. Pregnancy
can also alter the p.kinetics of various antibiotics.
e) Lactation:
Drugs administered to lactating mothers may
enter the nursing infant via the breast milk.
Though the concentration of drug excreted in
milk is small but may be adequate to cause
serious problem in babies.
 For example nalidixic acid and sulfonamides
secreted in milk may cause haemolysis in children
with glucose-6-phosphate dehydrogenase
deficiency. Sulfonamides through breast milk may
predispose the nursing child to kernicterus
(bilirubin-induced brain dysfunction).
f) Drug Allergy:
β-lactam derivatives and their degradation
products are notorious for provoking allergic
reactions. Patients with history of allergy are
more susceptible to allergic reactions.
 Thus patients may be interrogated and tested
before prescribing the antimicrobial. Drug-fever
should not the mistaken for a sign of continued
infection.
g) Host Defense Mechanisms:
The functional state of host defence mechanisms
is critical determinant of therapeutic
effectiveness of antimicrobials. Both humoral and
cellular immunity are important. Frequently,
infections may be successfully treated with
bacteriostatic agent by inhibition of replication in
the immunocompetent host.
Whereas bactericidal drugs are needed to cure
the infection in the individuals whose defense
mechanisms are impaired. The most striking
example is of AIDS patients, having impaired
immune responses. The therapy for various
opportunistic infections in AIDS patients is usually
suppressive but not curative. Most AIDS patients
respond to conventional therapy for bacteremia
due to salmonella but relapse of infection occurs
even after prolonged treatment. The examples of
diseases in immuno-competent individuals
 include endocarditis, where phagocytic cells are
excluded from the infected site and bacterial
meningitis , phagocytic cell are ineffective
because of lack of opsonins.
h) Disorders of Nervous System:
Patients having disorders of nervous system are
more vulnerable to the risk of localized or major
seizures while taking high doses of pencilline G.
Neurotoxicity of β-lactam antibiotics correlates
with concentrations of drugs in CSF and this
usually occurs in patients with impaired renal and
hepatic functions.
5- LOCAL FACTORS:
Local factors at the site of infection may greatly
influence the effectiveness of antimicrobials in
curing the disease. Pus (consisting of phagocytes,
cellular debris, fibrin, protein and
microorganisms) reduces the antibacterial activity
of aminoglycosides by binding to them. Large
accumulation of Hb in infected haematomas can
bind to penicillins and tetracyclines and may
reduce their activity. The acid pH of abscess
cavities results in a marked loss of antimicrobials,
for example aminoglycosides, erythromycin and
clindamycin. However, drugs like
chlortetracycline and nitrofurantoin show more
activity in such acidic conditions.
 Penetration of antibiotics into infected areas like
abscess cavities is impaired because the vascular
supply is reduced, successful therapy of abscesses
requires drainage. The presence of foreign body in
the infected area is another important factor that
decreases the probability of successful therapy. This
factor has become increasingly important in the
present era of prosthetic cardiac valves, prosthetic
joints, pace markers, vascular prostheses and various
vascular and CNS shunts. The phagocytic cells
perceive the prosthesis as foreign body and in an
attempt to phagocytize and destroy it, degranulation
of phagocytes occurs.
This results in the depletion of intracellular
bactericidal substances. Thus the phagocytes
become relatively ineffective in killing pathogens,
rather pathogens may live in these cells, being
protected from most antimicrobial agents.
Furthermore, microbes may attach to foreign
bodies with the help of glycocalyx substrate and
microbes embedded in this substrate are
relatively resistant to the action of most
antibiotics. Infections involving foreign bodies
are characterized by frequent relapses and failure
even after long-term therapy with high doses.
 The success in such situations lies in the removal
of foreign body.
Cost of Therapy:
Very often several drugs exhibit similar efficacy in
treating an infection but they may vary greatly in
cost. Sometimes, there is many fold difference in
the prices of different brands of the same drug.
Thus cost of therapy may be taken into account,
after assessing the socio-economic status of the
patient, before making the final decision.
Prosthesis:
An artificial substitute for missing part of the body.
Glycocalyx:
Fibrous masses which extend from bacterial cell and
by means of which bacteria adhere to surfaces.
Bacteremia
the presence of bacteria in the blood.