Antimicrobials

Mode of Action
Mechanism of Resistance
Origin of Resistance
Spectrum of Activity
Classic Side Effects
PRINCIPLES OF ANTIMICROBIAL THERAPY
Selective toxicity

- differences in metabolism & structure

- 4 major sites : cell wall, ribosome, cell membrane, nucleic acids
A. Inhibition of Cell Wall Synthesis - Penicillins
Act by inhibiting transpeptidases (enzymes catalyzing final cross-linking
step in synthesis of peptidoglycan)

2 factors involved in mechanism of action:

Penicillin-binding proteins ( binds to receptors in bacterial cell membrane
and cell wall) *

Autolytic enzymes called murein hydrolases

- activated in penicillin treated cells hence degrading the peptidoglycan

* Resistance
A. Inhibition of Cell Wall Synthesis - Penicillins
- Bactericidal (more active during the log phase)

- B-lactam drugs

- Benzylpenicillin Disadvantages (addressed by modification in the side chain):

a) Limited effectiveness against gram negative rods
b) Hydrolysis by gastric acids (cannot be taken orally)
c) Inactivation by B-lactamases
d) Hypersensitivity (1-10%)
-Ig E mediated : anaphylaxis, bronchospasm, urticarial rash
-Ig G mediated : non-urticarial rash, hemolytic anaemia, nephritis, drug fever
Spectrum Activity
Table 10.2
A. Inhibition of Cell Wall Synthesis - Cephalosporins
A. Inhibition of Cell Wall Synthesis - Cephalosporins
- Mechanism : inhibits peptidoglycan cross-linking
- Broad range
- Newer Cephalosporins have expanded activity against gram negative
rods
- Well tolerated
- Fewer hypersensitivity reactions
Spectrum Activity
Table 10.3
A. Inhibition of Cell Wall Synthesis - Carbapenems
- Different from Penicillins and Cephalosporins due to the methylene group in
ring in place of sulfur

- Spectrum of activity:
Many gram positive cocci (strep, staph)
Most gram negative cocci (Neisseria)
Gram negative rods (Pseudomonas, Haemophilus, members of the
Enterobacteriaceae such as E Coli)
Anaerobes (Bacteroides, Clostridium)

- Examples: Imipenem/Cilastin, Ertapenem, Meropenem

A. Inhibition of Cell Wall Synthesis - Vancomycin
2 mechanisms:
- Instead of binding to the transpeptidase itself as like other B-lactam
drugs, Vancomycin binds directly to the D-alanyl-D-alanine portion
of the pentapeptide.

- Inhibits bacterial transglycosylase which synthesizes peptidoglycan

Not a B-lactam drug

MRSA
A. Inhibition of Cell Wall Synthesis - Vancomycin
Side Effects:

a) Red-Man Syndrome
b) Hypotension with flushing
c) Nausea & vomiting
d) Nephrotoxicity
e) Ototoxicity
Inhibition of Fungal Cell Wall Synthesis
- Echinocandins (Caspofungin and Micafungin) are lipopeptides
blocking the fungal cell wall synthesis by inhibiting enzyme that
synthesizes B-glucan.

- Spectrum of Activity:
Caspofungin Aspergillus, Candida, disseminated Candidiasis, invasive
aspergillosis that does not respond to amphotericin B

Micafungin esophageal candidiasis, prophylaxis for invasive Candida

infection
Spectrum Activity
Table 10.5
B. Inhibition of Protein Synthesis 30S Subunit
1. Aminoglycosides
- Bactericidal against gram negative rods

- Inhibitas initiation of complex and misreading of messenger RNA membrane damage

causing bacteria to die
- Examples

- Limitations:
a) Nephrotoxic
b) Toxic to auditory and vestibular portions of CN VIII
c) Poorly absorbed from GI Tract (cannot be given orally)
d) CSF penetration is poor (given intrathecally for meningitis)
e) Ineffective against anaerobes (transport into bacterial cell relies on oxygen)
B. Inhibition of Protein Synthesis 30S Subunit
2. Tetracyclines
- Bacteriostatic

- Blocking aminoacyl transfer RNA (tRNA) from entering the receptor site on ribosome (selectivity based on
greatly increased uptake into susceptible bacterial cells)

- Spectrum of activity : gram positives, gram negatives, mycoplasmas, chlamydiae, rickettsiae

- Examples: Doxycycline, Minocycline, Oxytetracycline

- Side Effects:
a) Diarrhea & Overgrowth by drug resistant bacteria (suppresion of GI tract flora)
b) Candida vaginitis (suppresion of Lactobacillus in vagina)
c) Brown staining of teeth in foetuses and young (contraindicated in pregnant women and children younger
than 8 years of age)
d) Iron chelators
e) Photosensitivity
C. Inhibition of Protein Synthesis 50S Subunit
1. Chloramphenicol
- Bacteriostatic against Salmonella typhi
- Bactericidal against Encapsulated organisms causing Meningitis

- Blocks action of peptidyltransferase, preventing synthesis of new peptide bonds

- Side effects:
a) Bone marrow toxicity (due to inhibition of protein synthesis in mitochondria)
Dose dependent (high prolonged dose, reversible)
Aplastic Anaemia (idiosyncratic, not dose dependent, weeks later, irreversible 1 in 30,000
patients)

b) Gray Baby Syndrome (gray skin, vomiting and shock) due to reduced glucuronyl transferase
activity in infants resulting in toxic concentrations
C. Inhibition of Protein Synthesis 50S Subunit
2. Macrolides
- Bacteriostatic by binding to the 50s subunit and block translocation.

- Eg:
a) Azithromycin for genital tract infection by Chlamydia Trachomatis,
respiratory tract infection by Legionella, Mycoplasma, Chlamydia
Pneumoniae, S. Pneumoniae
b) Erythromycin (similar as above, shorter half life hence more
frequent dose with more adverse effects)
c) Clarithromycin for Helicobacter infections, Mycobacterium avium-
intracellulare infections
C. Inhibition of Protein Synthesis 50S Subunit
3. Clindamycin
Spectrum of activity :
Anaerobes
Gram positive (Clostridium perfringes)
Gram negative (B.fragilis)

Side Effects: Pseudomembranous Colitis (suppression of normal flora

of bowel and overgrowth of drug resistant Clostridium difficile)
C. Inhibition of Protein Synthesis 50S Subunit
4. Linezolid
Against VRE, MRSA, S.Epidermidis, penicillin resistant pneumococci

Side Effects: Pseudomembranous Colitis (suppression of normal flora

of bowel and overgrowth of drug resistant Clostridium difficile)
D. Inhibition of Nucleic Acid Synthesis
1. Sulfonamides
- Against UTI by E.Coli, Otitis Media by S.pneumoniae, Shigellosis, Nocardiosis, Chancroid
- In combination with trimethoprim, against toxoplasmosis and PCP

- Block synthesis of tetrahydrofolic acid (required as a methy donor in synthesis of nucleic

acid precursors)

- Side Effects:
a) Drug related fever
b) Rashes
c) Photosensitivity
d) Bone marrow suppression
e) Erythema Multiforme, Steven Johnson Syndrome, TEN
D. Inhibition of Nucleic Acid Synthesis
2. Trimethoprim
- SPECTRUM OF ACTIVITY:
Against UTI, Pneumocystis pneumonia, Shigellosis
Prophylaxis in neutropenic patients to prevent opportunistic infections

- MECHANISTM : Inhibits dihydrofolate reductase

- Used with Sulfamethoxazole because:

a) Bacterial mutants resistant to one drug will be inhibited by the other
b) Acts synergistically
D. Inhibition of Nucleic Acid Synthesis
3. Fluoroquinolones
- Bactericidal that blocks bacterial DNA synthesis by inhibiting DNA gyrase

- Examples : Ciprofloxacin, levofloxacin, Norfloxacin, Ofloxacin

- Against LRT, GI, GU, Skeletal and Soft Tissues infections

- Side Effects:
a) Contraindicated in pregnant and below 18 as damages bone and cartilage.
b) Archilles tendonitis and tendon rupture (esp on steroids and above 60 y/o)
c) Peripheral Neuropathy
D. Inhibition of Nucleic Acid Synthesis
4. Flucytosine
- Antifungal that inhibits DNA synthesis

- A nucleoside analogue that is metabolized to fluorouracil inhibiting

thymidylate synthetase limiting supply of thymidine

- Against disseminated cryptococcal or candidal infections

(in combination with ampho B as resistant mutants emerge very rapidly
if used alone)
D. Inhibition of Nucleic Acid Synthesis
5. Rifampin
- Blocks mRNA synthesis by bacterial RNA polymerase

- Against:
a) For TB treatment in combination with other drugs,
b) prophylaxis for those in close contact with patients with meningitis
caused by N.meningitidis or H.influenzae,
c) Combination with others for prosthetic valve endocarditis by S
epidermidis
E. Alteration of Cell Membrane Function
Polymyxins (Polymycin E)
- The positively charged free amino groups act like a cationic detergent to
disrupt the phospholipid structure of the cell membrane
- Active against gram negative rods (P.aeruginosa, Acinetobacter baumannii,
carbapenemase producing Enterobacteriaceae

Daptomycin
- Disrupts cell membrane of gram positive cocci
- Bactericidal against :
S.aureus, S. epidemidis, S pyogenes, Enterococcus faecalis, E faecium
Methicillin resistant Staph aureus, S.epidermidis
Vancomycin resistant strains of S aureus, E.faecalis, E faecium
Alteration of Fungal Cell Membrane
(Amphotericin B)
- Disrupts cell membrane of fungi due to its affinity for ergosterol, a
component in fungal membranes.

- Rarely has resistant fungi

- Side Effects:
a) Nephrotoxicity (Liposomal Ampho B much lesser, but more expensive)
b) Fever
c) Chills
d) Nausea
e) Vomiting
 Alteration of Fungal Cell Membrane
Nystatin
- For Candidiasis

Terbinafine
- Blocks ergosterol synthesis by inhibiting sequelae epoxidase
- Against dermatophyte infections of skin, fingernails, toenails

Azoles
- Inhibits ergosterol synthesis (blocks cytochrome P-450 dependent demethylation of Ianosterol, precursor of
ergosterol)

- Eg:
a) Fluconazole for candidal and cryptococcal infections
b) Ketoconazole for blastomycosis, chronic mucocutaneous candidiasis, coccidioidomycosis, dermatophytic skin
infections
c) Voriconazole,
d) Itraconazole, for histoplasmosis and blastomyosis
e) Posaconazole for oropharyngeal candidiasis, prevention of Candida/Aspergillus infection in immunocompromised
individuals
- Clotrimazole and Miconazole only topically (too toxic to be given systematically)
Resistance
Origin
Inherent genes

Most dangerous/important is injudicious use of antibiotics

Agricultural and Veterinary use

4 major mechanisms

a) Bacteria produces enzymes

b) Synthesize modified targets

c) Reduce permeability

d) Actively export drugs

Genetic Changes
Chromosomal mutation
Acquisition of plasmid or transposon

- High versus Low level

** Plasmid Mediated Resistance clinically important

a) Occurs in many different species, especially gram negative rods
b) Plasmids frequently mediate resistance to multiple drugs
c) Plasmids have a high rate of transfer from one cell to another, by
conjugation
 SPECIFIC MECHANISM OF RESISTANCE
1.Penicillins/Cephalosporins
B-lactamases countered by clavulanate, sulbactam, tazobactam

Extended spectrum B-lactamases (ESBL)

- resistant to all penicillin/cephalosporin/monobactam
- sensitive to piperacillin/tazobactam

Changes in Penicillin Binding Proteins

- MRSA due to PBP2a
- Enterococcus faecalis
- Neisseria gonorrhoeae ( high level resistance penicillinase, low level resistance poor
permeability)

Tolerance
- Staph Aureus
 SPECIFIC MECHANISM OF RESISTANCE
2. Carbapenems
Carbapenemases that degrade the B lactam ring
- CRE Klebsiella, Escherichia, Pseudomonas

3. Vancomycin
Change in peptide component of peptidoglycan from D-alanyl-D-alanine to
D-alanine-D-lactate (Vanco unable to bind)
- VRE
 SPECIFIC MECHANISM OF RESISTANCE
4. Aminoglycosides
3 mechanisms :

- Modification of drugs by plasmid encoded phosphorylating,

adenylating and acetylating enzymes

- Chromosomal mutation

- Decreased permeability to drug

 SPECIFIC MECHANISM OF RESISTANCE
5. Tetracyclines

Failure of drug to reach an inhibitory concentration inside

the bacteria due to plasmid-encoded processes that either:
- reduce the drug uptake or
- enhance its transport out of the cell
Others
Chloramphenicol plasmid encoded acetyltransferase acetylating the drug
thus inactivating it
Erythromycin plasmid encoded enzyme methylating the 23S rRNA blocking
the binding of the drug
Non Genetic Basis of Resistance
1) Walled off by within an abscess cavity that the drug cannot
penetrate effectively
2) Resting state (such as MTB in dormant state)
3) Protoplasts
4) Presence of Foreign bodies (surgical implants/catheters)
5) Artifacts making it appear that the organisms are resistant
- failure of drug to reach approriate site ( eg CSF penetration)
- wrong drug, wrong dosage
- compliance/patient factor
THANK YOU