Antibacterial Agents

Dr S Khoza Department of Clinical Pharmacology University of Zimbabwe

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Lecture Objectives

Classification of antibiotics by mechanisms of action Discuss clinical use of different antibiotics Discuss different mechanisms of resistance of antibiotics

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Introduction

Prior to antibiotics, many infectious diseases were considered incurable Discovery of penicillins by Andrew Fleming in 1928
observed antibacterial effect of substance secreted by penicillium notatum mold

Other naturally synthesised antibiotics: tetracycline, streptomycin and cephalosporins

Antibiotic era

Infectious diseases no longer associated with high mortality rates

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Bacteria Cell

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Classification of Antibiotics
Inhibition of cell wall synthesis

E.g. Penicillins, cephalosporins and cephamycins, (Betalactams), vancomycin E.g. Aminoglycosides, tetracyclines, macrolides, amphenicols, lincomycins

Inhibition of protein synthesis

Inhibition of nucleic acid synthesis and folic acid synthesis

E.g. Sulphonamides, quinolones, azoles (metronidazole and tinidazole), rifampicin

Disruption of cell membrane function Azole (ketoconazole, fluconazole) and polyene antifungal agents
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Inhibition of Cell Wall Synthesis

Beta-lactams

Penicillins Cephalosporins and cephamycins

Carbapems, e.g. meropenem, imipinem

Monobactams, e.g. aztreonam Beta-lactamase inhibitors, e.g. clavulinic acid Vancomycin
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Mechanism of Action

Penicillins, cephalosporins, monobactams and carbapenems interfere with synthesis of cell wall peptidoglycan attach to penicillin-binding proteins Inhibits the transpeptidation enzyme that crosslinks the peptide chains attached to the backbone of the peptidoglycan
Leading to cell wall rupture due to osmotic pressure

Inactivate an inhibitor of autolytic enzyme in cell wall Bactericidal

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Resistance to Penicillins and Cephalosporins

production of beta-lactamases
staphylococci, neisseria gonorrheae, haemophilus sp., E. coli,

reduction in permeability of the outer membrane

e.g. gram ve bacteria: have impermeable outer cell membrane

Efflux pump
Transportation of beta-lactam antibiotics across the outer membrane from peri-plasm

modified penicillin binding sites

streptococcus pneumoniae Methicillin resistance in staphylococci

lack of cell wall

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Classification of penicillins

Narrow-spectrum beta lactamase sensitive Broad spectrum beta lactamase sensitive Beta-lactamase resistant Extended spectrum
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Narrow-spectrum beta-lactamase sensitive

Benzyl penicillin (Penicillin G, X-pen) Phenoxymethypenicillin (Penicillin V)

Highly active against gram-positive cocci Active against some gram-negatives penicillin G, X-pen
treatment of choice for many infections life-saving in meningococcal meningitis caused by neisseria meningitidis Pneumococcal pneumonia, streptococcal pneumonia, endocarditis Anthrax, syphillis, diphtheria, clostridial infections (gas gangrene)

Penicillin V: less potent than benzyl penicillin

Oral preparation Streptococcal pharyngitis

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Broad-Spectrum, Beta-lactamase Sensitive

Spectrum similar to benzyl penicillin but greater activity against gram ve bacteria Less active than benzyl penicillin against gram +ve cocci

Amoxycillin; ampicillin (major side effect: diarrhoea)

Useful activity against H. influenzae

Combination with beta-lactamase inhibitors protects from beta-lactamase

clavulanic acid (Augmentin): Co-amoxiclav sulbactam tazobactam

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Beta lactamase-resistant Penicillins

Appropriate use should be limited to staphylococci infections Less active than benzyl penicillin against other penicillin-sensitive microorganisms

Cloxacillin, oxacillin and dicloxacillin flucloxacillin, methicillin, nafcillin Nafcillin most active against staph. aureus
spectrum similar to that of benzyl penicillin but less potent
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Extended spectrum

Cabernicillin, ticarcillin, piperacillin, azlocillin Beta-lactamase sensitive Spectrum similar to broad-spectrum plus pseudomonas spp, proteus spp
gram +ve plus gram ve cocci, gram +ve rods, gram ve anaerobic rods

Tend to inactivate aminoglycosides in vitro

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Pharmacokinetics of penicillins

Well absorbed orally

Ampicillin, amoxycillin, dicloxacillin

Absorption impaired by food (except amoxycillin)

Should be administered at least 1-2 hours before or after a meal

Excretion mainly by kidneys

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Adverse Reactions

Hypersensitivity reactions
Skin reactions, urticaria, serum sickness Acute anaphylactic shock

Alteration of GIT bacterial flora

Super infections
Staphylococci, pseudomonas, proteus, or yeasts (vaginal candidiasis) Pseudomembranous collitis ( caused by C. difficile; treated with vancomycin or metronidazole)

GIT disturbances, nausea, vomiting, diarrhoea

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Adverse Reactions

Ampicillin
Pseudomembranous collitis

Nafcillin Neutropenia Oxacillin Hepatitis Methicillin Interstitial nephritis No longer used clinical for this reason

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Cephalosporins

First generation

cefalexin, cefazolin, cefaclor, cefradine very active against gram +ve cocci S aureus gram ve: E coli, Klebsiella pneumoniae and proteus mirabilis

Second generation Third generation

Cefamandole, cefuroxime, cefoxitin, H. influenzae + those covered by first generation Ceftriaxone, ceftazidine, cefotaxime, cefixime Expanded gram negative coverage

Fourth generation: cefepime

Time-dependent bacterial killing
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Adverse Effects

Hypersensitivity reactions
Similar to those seen with penicillins Cross-sensitivity with penicillins (10%)

Nephrotoxicity (cefradine) Diarrhoea (C. difficile)

Super infections, candida ablicans

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Inhibition of protein synthesis

Aminoglycosides
Tetracyclines Amphenicols Macrolides Lincomycin
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Mechanism of Action

Bacteria have 70S ribosomes, humans 80S

Aminoglycosides and tetracyclines: bind to 30S ribosomal subunit

Chloramphenicol, macrolides, clindamycin, streptogramins: bind to the 50S ribosomal subunit

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Aminoglycosides

Streptomycin, neomycin, kanamycin, amikacin, gentamicin, tobramycin

Bactericidal: irreversible inhibition of protein synthesis Bind to 30S ribosome

Interfere with the initiation complex of peptide formation Induce misreading of the code on mRNA template
Abnormal proteins lead to cell death

Breakup of polysomes into non-functional monosomes

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Aminoglycosides: Resistance

Production of adenylation, acetylation, and phosphoration enzymes

Altered permeation or transport

Deletion or alteration of receptor protein Anaerobic microorganisms

Penetration into cell membrane depends partly on oxygen-dependent transport

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Aminoglycosides: Pharmacokinetics

Water soluble, poorly absorbed from GIT

Mostly administered iv or im

Eliminated unchanged by glomerular filtration

Attain high concentration in urine

Significant accumulation in renal cortex

Need for therapeutic drug monitoring
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Aminoglycosides: Clinical Use

Antibacterial spectrum Aerobic gram ve and gram +ve Widely used for gram negative enteric bacteria

Gram negative bacillary infections

Septicaemia, renal, pelvic and abdominal sepsis Gentamicin, drug of choice

Bacterial endocarditis
Other infections: tuberculosis, plague, brucellosis

Topical uses
Neomycin conjunctivitis, ear infections
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Aminoglycosides: Adverse reactions

Ototoxicity: hearing loss, vestibular damage, ataxia, tinnitus Nephrotoxicity

Dose-related

Neuromuscular blockade: high doses

Other reactions
Rashes, haematological abnormalities (bone marrow suppression, haemolytic anaemia, bleeding)
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Tetracyclines

Oxytetracycline, chlortetracycline, tetracycline, doxycycline, minocycline, tigelcycline Prototype broad spectrum antimicrobial drugs Bacteriostatic

Bind to 30S, block the binding of aminoacyl-tRNA to the acceptor site on the mRNA-ribosome complex
Prevents addition of new amino acids
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Tetracyclines: Antibacterial Spectrum

Very wide spectrum

Gram +ve and gram ve Mycoplasmia Rickettsia

Chlamydia spp
Spirochaetes Some protozoa (e.g. amoebae); doxycycline for malaria
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Tetracyclines: Resistance

Impaired influx or increased efflux by an active transport protein Ribosome protection due to the production of proteins that interfere with tetracycline binding to the ribosome
Enzymatic inactivation
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Tetracylines: Adverse reactions

GIT: nausea, vomiting, diarrhoea (direct irritation) Modification of normal flora: candida, pseudomonas, staphylococci, clostridia may become prominent Vitamin B complex deficiency Deposition in bones and teeth in young children: contraindicated in children, pregnant women or nursing mothers.

Hepatic damage hepatic necrosis

Kidney toxicity Photosensitization Dizziness, vertigo
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Macrolides

Erythromycin, clarithromycin, azithromycin, spiramycin Bind to 50S ribosomal subunit Inhibit aminoacyl translocation reactions and the formation of initiation complexes Bacteriostatic/bacteriocidal
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Macrolides: Antibacterial Spectrum

Similar to penicillins
Good alternatives to penicillins in patients allergic to penicillins

gram +ve: pneumococci, streptococci, and staphylococci Not effective against most gram ve, except
Mycoplasma, legionella, chlamydia trachomatis, N. gonorrhoea
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Macrolides: Erythromycin

More effective against gram positive Similar spectrum penicillins

Oral absorption is best with erythromycin estolate (in the presence of food) Uses: mycoplasmia pneumoniae in children, pertussis, chlamydial infections, staphylococcus aureus, streptococcus pyrogens, streptococcus pneumoniae
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Macrolides: Resistance

Reduced permeability of the cell membrane or active efflux Production of esterases that hydrolyze macrolides
Modification of ribosomal binding site

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Adverse effects: Macrolides

Hypersensitivity reactions GIT: anorexia, vomiting and diarrhoea Cholestatic jaundice (estolate salt of erythromycin) Inhibit cytochrome P450 3A
Interactions with warfarin, carbamazepine, theophylline, terfenadine
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Clindamycin

Structurally, a lincomycin or lincosamide Mechanism of action similar to macrolides and chloramphenicol Antibacteria spectrum
Similar to macrolides (partial cross-resistance) and benzyl penicillin (includes penicillin-resistant staphylococcus) Effective against anaerobes e.g. Bacteriodes fragilis

Uses
Bone and join infections, dental infections, serious abdominal sepsis

Adverse effects
Pseudomembranous collitis

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Chloramphenicol

Broad spectrum Binds reversibly 50s

interferes with incorporation of amino acids into newly formed peptides

Blocks the action of peptidyl transferase Also inhibits mitochondrial protein synthesis in mammalian bone marrow cells Bacteriostatic: gram +ve and ve; rickettsiae Bactericidal: H.influenzae, neisseria meningitidis
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Chloramphenicol
Resistance decreased permeability production of chloramphenicol acetyltransferase Clinical uses salmonella: typhoid fever serious h. influenzae infections meningococcal and pneumococcal CNS infections topically: eye infections
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Chloramphenicol: Pharmacokinetics

Chloramphenicol is inactivated by conjugation with glucuronic acid in the liver

In the neonante (esp. the premature), glucorinidation is slow

Penetrates well into all tissues, including CSF and brain
Even in the absence of meningeal inflammation
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Chloramphenicol: adverse reactions

GIT disturbances

Nausea, vomiting and diarrhoea Candidiasis Aplastic anaemia: 1 in 24,000-40,000 / 1 in 18,000 100,000

Bone marrow depression

Grey baby syndrome: lack of glucuronic acid conjugation mechanism

Circulatory collapse skin develops cyanotic grey colour; flaccidity, low tempertaure, vomiting, diarrhoea 40% mortality

Inhibits liver enzymes

Phenytoin, warfarin, tolbutamide and chlorpropamide

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Inhibition of Nucleic Acid Synthesis

Sulphonamides
Quinolones Azoles
Metronidazole, tinidazole (antibacterial and antiprotozoal)

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QUINOLONES

Norfloxacin, ciprofloxacin, ofloxacin, levofloxacin broad spectrum (gram +ve and gram ve) Nalidixic acid narrow spectrum; no systemic antibacterial activity Gatifloxacin, gemifloxacin, moxifloxacin
Improve activity against gram +ve

Block bacterial DNA synthesis

Inhibit topoisomerase II (DNA gyrase) Inhibits topoisomerase IV

Prevents relaxation of positively supercoiled DNA Prevents DNA transcription and replication
interferes with separation of replicated chromosomal DNA into the respective daughter cells during cell division.

Bactericidal

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Quinolones: Mechanism of Action

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Quinolones: Resistance

Mutation in the quinolone binding region of target enzyme Altered permeability

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Quinolones: Adverse Effects

GIT: nausea, vomiting, diarrhoea Headache, dizziness and skin rashes

Photosensitivity
Super infection with streptococci, C. difficile, and candida QTc prolongation
Gatifloxacin, levofloxacin, gemifloxacin, moxifloxacin Theophylline toxicity

Interact with theophylline

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Quinolones use in children

May damage growing cartilage and cause an arthopathy Not routinely recommended for patients under 18 years of age

Arthropathy is reversible

May be used in children with serious infections

E.g. Pseudomonal infections in patients with cystic fibrosis No safety data available

Use to be avoided in pregnancy

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Sulphonamides and Trimethoprim

sulphamethoxazole, sulphadiazine, sulphamethizole, sulphadoxine, sulphapyridine, sulphasalzine (COTRIMOXAZOLE) Inhibit both gram +ve and gram ve bacteria Nocardia, chlamydia trachomatis, and some protozoa

Structural analogues of p-amino-benzoic acid (PABA)

Bacteriostatic Bactericidal in combination
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Mechanism of Action

competitive inhibition
sulphonamides trimethoprim Purines DNA

PABA

Dihydrofolic acid

Tetrahydro Folic acid

Dihydropteroate synthase

Dihydrofolate reductase

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Mechanism of Action

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Sulphonamides: Resistance

Exogenous sources of folic acid Over-production of PABA Structural change in the folic acid synthesising enzyme
Low affinity for sulphonamides

Loss of permeability

Overproduction of dihydrofolate reductase

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Sulphonamides: Adverse Reactions

Allergic reactions Fever, skin rashes, photosensitivity, urticaria Nausea, vomiting and diarrhoea Stevens-Johnson Syndrome May precipitate in urine: crystalluria, haematuria, or obstruction Haemolytic and aplastic anaemia, granulocytopenia and thrombocytopenia
Glucose-6-phosphate dehydrogenase deficiency

Pregnancy: kernicterus in new borns

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Other Antibacterial Agents

Quinupristin-dalfopristin: gram +ve

effective therapy against MRSA and VRE (vancomycin resistant enterococci)

Linezolid: effective therapy against MRSA and VRE (vancomycin resistant enterococci) Fusidic acid Metronidazole and tinidazole

Mupirocin: gram +ve topical infections (skin, nasal)

Colistin: gram -ve

Polymyxin B: gram ve infections, mostly skin, eye, external ear infections

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Summary

Three (or Four) classes of antibacterial agents Penicillins and cephalosporins share a lot of similarities Therapeutic drug monitoring essential with aminoglycosides Various mechanisms of resistance
Related to main mechanisms of action and method of transportation
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Reference

Katzung BG, Masters SB, Trevor AJ. Basic and Clinical Pharmacology. 11th Edition. McGrawHill Lange. 2009

Bennet PN, Brown MJ. Clinical Pharmacology. 10th Edition. Churchill Livingstone Elsevier. 2008.
Rang HP, Dale MM, Ritter JM, Flower RJ, Henderson G. Rang and Dales Pharmacology. 7th Edition. Churchill Livingstone Elsevier. 2012.
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