CHEMOTHERAPEUTIC AGENTS

Dr. R. Tan

Chemotherapeutic Agents
- are compounds that destroys pathogenic microorganism or inhibit their growth - one of the most valuable method of treating infection - most common agents used are:  Antibiotics  microbial products or their derivatives that are capable of killing susceptible microorganism or inhibiting their growth

DESIRABLE PROPERTIES: 1. Selective toxicity

- it must inhibit or destroy the pathogen without injury to the host

2. Bactericidal rather than bacteriostatic 3. One to which susceptible organisms do not become genetically or phenotypically resistant 4. Effective against a broad range of microorganism 5. Should not be allergenic; nor should continued administration of large doses cause adverse side effects 6. Remain active in the presence of plasma, body fluids, or exudates 7. Water soluble and stable; bactericidal level should be rapidly reached and maintained for prolonged period 8. Cheap

ANTIBIOTICS

  

Are chemical substance produced by various species of microorganisms or to a similar substance produced wholly or partially by chemical synthesis, which in low concentrations inhibit the growth of other microorganisms these substances functions to limit microbial growth by killing or inhibiting their growth some are semi-synthetic in which the natural active component in the molecule is combined with a synthetic group Antibiotic producing organisms:
Bacteria Fungi Bacillus Penicillium Streptomyces Cephalosporium Micromonospora

 Mechanism of action: 1. Interfere with cell wall synthesis 2. Interfere with cell membrane function 3. Interfere with nucleic acid metabolism 4. Interfere with protein synthesis

Cell Wall Inhibitors

 Any substance that destroys the cell wall or that prevents the synthesis or incorporation of the wall polymers in growing cells leading to the development of osmotically sensitive cells and death  Agents with this mode of action are highly specific with low toxicity  Species of eubacteria that lacks a cell wall (ex. Mycoplasma) are not inhibited by these agents  Agents:
-lactam antibiotics Vancomycin Cycloserine Bacitracin

I. LACTAM ANTIBIOTICS Contain a unique 4 member -lactam ring Agents: - Penicillin - Cephalosphorins - newer agents: Penems, Carbapenems & Monobactams Bactericidal Penicillin-binding-protein (PBP) - are enzymes that catalyze the last steps of peptidoglycan biosynthesis - Higher-molecular-weight PBP are the killing site for Lactam antibiotics - Low-molecular-weight PBP are not essential for viability

Resistance to -lactam Antibiotic Attributed to 3 mechanisms:  Inactivation of the drug - the major basis for bacterial resistance to PCN - Due to -lactamase = enzyme which split the -lactam ring of PCN & Cephalosporin between the C & N atoms to form inactive compounds
 Alteration in the amount or affinity of the Penicillin-bindingproteins (target site)  Blocking of transport of drug into the cell - Gram (-) bacteria have a complex outer membrane that retards the entry of -lactam antibiotic - Most Gram (-) are resistant to Penicillin

PENICILLIN basic structure consist of thiazolidine ring joined to a -lactam ring which can be inactivated by -lactamase Penicillinase - specific type of -lactamase, showing specificity for penicillins PCN nucleus (6-aminopenicillamic acid) is the primary structural requirement for biologic activity MOA: - affect bacteria by interfering with the normal maintenance and synthesis of bacterial cell wall - inhibit the transpeptidation enzyme involve in cell wall synthesis active against both gram (+) and gram (-) bacteria

Classifiication: Naturally occuring penicillins - Produced by culturing molds (Penicillium nonatum) and collecting and purifying the penicillin - Ex: Benzylpenicillin Phenoxymethylpenicillin Semi-synthetic penicillins - are produced by making chemical alterations in the structure of a naturally occurring penicillin - Ex: Penicillinase-resistant Penicillin Extended spectrum Penicillin Anti-pseudomonal penicillin

Naturally occuring penicillins

 Benzylpenicillin / Penicillin G Most useful administered parenterally (Penadur) Disadvantage: - inactivated by acidic pH of gastric juice - destroyed by Penicillinase - hypersensitivity reactions DOC for Streptococcus pyogenes & S. pneumonia highly effective against most gram (+) and gram (-) cocci Least susceptible to some gram (+) cocci: enterococci and Penicillinase-producing S. aureus

Phenoxymethylpenicillin / Penicillin V A side chain variant of Pen G Has the same antimicrobial spectrum Advantage: more stable in acid medium, thus better gastrointestinal absorption can be given orally (Sumapen)

Semi synthetic Penicillin

 Penicillinase-resistant penicillins DOC for penicillinase-resistant organisms especially S. aureus and S. epidermidis An alteration of the side chain has provided protection for the -lactam ring from the action of -lactamase without removing its antibacterial activity Includes:
- Methicillin and Nafcillin - acid-labile, less active than penicillin G - Isoxazolyl PCN (Oxacillin, Cloxacillin & Dicloxacillin) - Combine resistance to -lactamase with resistance to gastric acid

 Extended-spectrum penicillins The most striking change brought about by chemical manipulation of the penicillin side chain is an increase of activity against gram negative organisms

Ampicillin, Amoxicillin, Aminopenicillin - administered orally - has a broad-spectrum of activity - acid-stable but -lactamase sensitive - highly active against gram (+) and gram (-) bacteria (H. influenzae, E. coli, Proteus mirabilis, Salmonella & Shigella)

 Anti-Pseudomanal penicillins Carboxypenicillins (Carbenicillin and Ticarcillin) - both have broad spectrum activity - active against gram (-) bacteria including Pseudomonas at the expense of diminishing activity against gram (+) org. - More active against strains of Enterobacter, Serratia, and certain strains of Proteus - acid-stable

Ureidopenicillins (Azlocillin, Mezlocillin, Piperacillin) - More inhibitory to P. aeroginosa than carboxy derivatives - Have activity against streptococci that is similar to Ampicillin

CEPHALOSPORINS
- Produced from fungus Cephalosporium - mechanism of action similar to penicillin in inhibiting the transpeptidation reaction during peptidoglycan synthesis - all these drugs are derivatives of cephem nucleus, (7-amino-cephalosporamic acid) , lends itself to modification which alters both microbiologic activity and pharmacologic properties - contain a -lactam ring structure similar to penicillin - inactivated by -lactamase

Classification of Cephalosporins
First Cephalothin Generation Cefazolin Cephalexin Cephaloridine Cephapirin Cephadroxil Cephradine Cefacetrile Cephaloglycin Cephalonium Cefatrizine Cefazaflur - moderate-spectrum, active against penicillinase-producing, methicillinsusceptible staphylococci and streptococci - have activity against some gram (-) : E. coli, K. pneumoniae, and P. mirabilis - no activity against B. fragilis, enterococci, methicillin-resistant staphylococci, Pseudomonas

Second Cefaclor Generation Cefonicid Cefprozil Cefuroxime Cefuzonam Cefmetazole Cefotetan Cefoxitin

- greater Gram (-) spectrum while retaining some activity against Gram (+)cocci - more resistant to beta-lactamase

with anti-anaerobe activity

Third Generation

Cefotaxime Ceftriaxone Ceftizoxime Cefmenoxime Cefcapene Cefdaloxime Cefdinir Cefditoren Cefetamet Cefixime Cefpodoxime

- broad spectrum of activity - further increased activity against Gram () organisms while decreased activity for Gram (+) organisms - useful in treating hospital-acquired infections - they can penetrate the CNS thus making it useful in treating meningitis caused by S. pneumoniae, N. meningitidis, H. influenzae, and susceptible E. coli, Klebsiella, and in the treatment of penicillin-resistant N. gonorrheae

Cefsulodin Cefoperazone Marked activity for Pseudomonas Ceftazidime

Fourth Cefepime Generation Cefclidine Cefluprenam Cefoselis Cefozopran Cefpirome Cefquinome

- Are extended-spectrum agents with similar activity against Gram (+) org. as first-generation cephalosporins and Gram (-) - have a greater resistance to -lactamases than the third-generation cephalosporins - Many can cross the blood-brain barrier and are effective in meningitis - used against Pseudomonas aeruginosa

Other B-lactam antibiotics MOA similar to penicillin have a -lactam ring and is resistant to -lactamase a) Thienamycin - are Carbapenem compounds that are stereochemically different from penicillin and cephalosporins - Imipenem a thienamycin in clinical use active against all medically important organism including organism frequently resistant to other -lactam antibiotics (S. aureus, S. faecalis, P. aeroginosa, Enterobacteriaceae, B. fragilis and -lactamase producing strains of H. influenzae and N. gonorrheae)

b) Monobactam - constitute a unique family of B lactams w/ a monocyclic nucleus - synthetic derivative: Aztreonam - has excellent activity against aerobic gram (-)such as the Enterobacteriaceae, Pseudomonas, Gonococci and Hemophilus c) B-lactamase inhibitors - several B lactams have been developed that function as B-lactamase inhibitors - such agents have little intrinsic antibacterial activity, but when combined with a B-lactam, they protect the suceptible B-lactam from degradation and allow it to exert its lethal effect - Clavulanic acid and Sulbactam - act synergically with amoxicillin, ampicillin, piperacillin, mezlocillin and cefoperazone

II. CYCLOSERINE - inhibit peptidoglycan synthesis - the molecular basis for its bactericidal activity lies in its structural similarity with D-alanine - broad-spectrum antibiotic used to treat patient with TB - Its use is limited because it causes CNS toxicity; thus given for re-treatment of drug resistant cases, where it is administered with 3 or more drugs

III. VANCOMYCIN - it interferes with peptidoglycan biosynthesis by binding rapidly and irreversibly to the acyl-D-alanine terminus of a membrane bound peptidoglycan precursor - narrow-spectrum, bactericidal antibiotic against many gram (+) cocci - alternative drug in patient who are allergic to -lactam agents - for serious infection caused by methicillin resistant S. aureus (MRSA) - drug of choice for antibiotic-associated colitis caused by C. difficile

IV. BACITRACIN - is a polypeptide antibiotic produced by strain of Bacillus subtilis

- it inhibits peptidoglycan synthesis by preventing reentry of lipid carrier into the reaction cycle

- bactericidal for many gram (+) organism and pathogenic Neisseria - highly toxic: used for topical application only

Cell Membrane Inhibitors

Cell membrane poses an osmotic barrier to free diffusion between the internal and external environments function: - it effects the concentration of metabolites and nutrients within the cell - serves as a site for respiratory and certain biosynthetic activities - certain antibiotics impair 1 or more of these functions, resulting in major disturbances in the viability of the cell
- agents: Polymixin Polyenes Azoles

1. POLYMXIN produced by Bacillus polymyxa MOA: binds specifically to the outer surface of cell membrane, altering their structure and osmotic properties members of this group are desinated by the letters A, B, C, D, E but only Polymixin B and Polymixin E (colistin) are currently of clinical use spectrum of activity is restricted to gram (-) organism - reserved drug for the treatment of severe Pseudomonas infection when organism is resistant to other antibiotics or the patient is intolerant of the preferred drug

2. POLYENES are macrolide antibiotics, most important of which are antifungal agents MOA: binds to sterol in fungal membrane causing disruption of membrane permeability resulting to leakage of cell content selectively inhibit organisms whose membrane contain sterols (ergosterol) active against yeast, fungi and other eucaryotic cells but inhibitory to procaryotic organism Drug-induced resistance:
1. Decrease in the membrane ergosterol content 2. Modification of membrane sterols to one that bind less efficiently to polyenes

Examples of Polyenes: Amphotericin B - cornerstone of antifungal therapy - active agent most deep-seated fungi infection - nephrotoxic and used only for serious life-threatening infection Nystatin - use to treat superficial or topical infections caused by Candida

Imidazoles Triazoles The difference between the imidazoles and the triazoles involves the mechanism of inhibition of the cytochrome P450 enzyme - this interrupts the conversion of lanosterol to ergosterol, a component of the fungal cell membrane AZOLES The triazoles have been shown to have a higher specificity for the cytochrome P450 than imidazoles, thereby making them more potent than the imidazoles

IMIDAZOLES Ketoconazole, Miconazole, Clotrimazole are broad-spectrum antifungal agents active against yeast dermatophytes and dimorphic fungi MOA: - acts by interfering ergosterol synthesis by the fungal cell
- disrupt fungal membrane permeability - inhibit sterol synthesis

- Miconazole and Clotrimazole - are limited to topical application only - used as a treatment of cutaneous and vaginal candidiasis - Ketoconazole given orally, very effective for superficial and deep mycotic infection in human

TRIAZOLE Itraconazole, Fluconazole it is a lipophilic agent with broad spectrum of activity against yeast and dimorphic fungi MOA same with Imidazole better tolerated when given orally than the Imidazole effective in the treatment of dermatophytosis, chromomycosis, sporotricosis, and in some deep mycoses and opportunistic infection

Inhibitors of DNA Function

Any agent that disturbs the structure of the organized double helix of DNA is potentially capable of causing profound effects on all phases of cell growth and metabolism Mode of action inhibit cross linkage and intercalation between the stacked bases of the double helix DNA Agents:
Quinolones Mitomycin Metronidazole Novobiocin

1. QUINOLONES all agents in the quinolone class are synthetic products it selectively and reversibly blocks DNA replication in susceptible organisms

Examples: Nalidixic acid Norfloxacin Ciprofloxacin

Nalidixic acid - first to be introduced as derivative of naphthyridine compound - inhibit the subunit A of DNA gyrase and induce the formation of a relaxation complex analogue - bactericidal - for uncomplicated UTI caused by gram (-) organisms

 Norfloxacin - most useful flourinated quinolone - 100x more active than Nalidixic acid - spectrum of activity includes Enterococci, Staphylococci and Pseudomonas - used to treat UTI Ciprofloxacin - most potent of the quinolones - active against most strains of gram (-) and gram (+) bacteria that cause urinary tract infection - showed promising result with oral use in prophylactic selective decontamination of the intestine in a neutropenic patient

2. MITOMYCIN - converted enzymatically to a highly reactive hydroquinone derivatives that acts as a bifunctional alkalyting agent which acts on the guanine residues of DNA - under certain condition blocks the synthesis of host cell DNA - its toxicity prohibits its clinical use 3. METRONIDAZOLE - effective antimicrobial agent for infection caused by anaerobic bacteria and some protozoans - no effect on facultative and aerobic organism - key feature of its microbial activity is the reduction of its nitro group

4. NOVOBIOCIN - bactericidal for a variety of bacteria, especially among gram (+) bacteria - primary inhibitory effect is on the replication of DNA - target site is the subunit B component of the DNA gyrase, which inhibits the supercoiling of the DNA - at present, there are no valid indication for the therapeutic use of novobiocin

Inhibitors of Protein Synthesis and Assembly

- Protein synthesis is the end result of 2 major processes: - DNA-dependent RNA synthesis ( transcription) - RNA-dependent protein synthesis (translation) Inhibitors of transcription Inhibitors of translation - Inhibitors of the 30s Ribosomal subunit - Inhibitors of the 50s Ribosomal Subunit Inhibitors of Protein Assembly Inhibitors of Tetrahydrofolate Synthesis (Folic acid synthesis) Inhibitors of dihydrofolate reductase

Inhibitors of Transcription
during transcription, the genetic information in DNA is transferred to a complementary sequence of RNA nucleotides by the RNA polymerase antibiotics alter the structure of the template DNA or inhibit the RNA polymerase will interfere with the synthesis of RNA, and consequently with protein synthesis Actinomycin - active against gram (+) and gram (-) bacteria - toxic; with limited clinical use

 Rifampicin - are ansa compounds which contain an aromatic ring system spanned by a long aliphatic bridge - Rifampin
most useful member of the group

effective against gram (+) organism and mycobacteria major drug for the treatment of tuberculosis, leprosy & as prophylaxis against meningococcal meningitis

Inhibitors of translation
translation of mRNA into protein are divided into 3 major phases: a) initiation : protein synthesis starts with the association of mRNA, a 30s ribosomal subunit and formyl-methionyltransfer RNA to form a 30s initiation complex b) elongation - amino acids are added 1 at a time to a growing polypeptide on a sequence directed by mRNA - this is the phase that is most susceptible to inhibition by a number of antibiotics - ribosome is the target site c) termination of polypeptide chain - enzyme catalyzing peptide formation is peptidyl transferase (part of 50s subunit) - termination is triggered when a chain termination signal (UAA, UAG or UGA) is encountered at the site of the ribosome

Inhibitors of the 30s Ribosomal subunit

Nitrofurans Aminoglycoside Tetracycline

NITROFURANS - Nitrofurantoin - MOA: inhibit protein synthesis by blocking the initiation of translation - used clinically to treat urinary tract infection especially patient unable to tolerate Sulfonamides - good activity against gram (+) and gram (-) organisms - most active against E. coli, Klebsiella, Enterobacter and S. faecalis - at present, it is recommended only for uncomplicated UTI

 AMINOGLYCOSIDE
- includes: Streptomycin, Neomycin, Kanamycin, Tobramycin, Gentamicin and Amikacin

- MOA: binds to 30s ribosomal subunits and inhibit protein synthesis - may irreversively block initiation of translation or cause mRNA misreading or both - toxic , poorly absorbed orally, poor penetration to CSF and rapidly excreted by the kidneys - can cause nephrotoxicity, ototoxicity , neuromuscular paralysis - Streptomycin - bactericidal for gram (+), gram (-) bacteria and M tuberculosis - drug of choice F. tularensis and Y. pestis infection - Gentamicin, Tobramycin and Amikacin - active against gram (-) bacteria including Pseudomonas - Neomycin - restricted to the pre-operative suppression of intestinal flora

3. TETRACYCLINES are family of broad-spectrum antibiotics active against gram (+) and gram (-) bacteria, Mycoplasma, Rickettsia and Chlamydia 2nd to penicillins & Cephalosporins inhibit protein synthesis by combining with the 30s subunits of the ribosome only bacteriostatic Most undesirable side effect: - superinfection secondary to incomplete oral absorption inhibition of normal intestinal flora - deposition of drug in calcified tissue staining and impairment of structure of bones and teeth Bacteria develop drug resistance to tetracyclines by becoming less permeable to the antibiotic

 includes the parent compound, Tetracycline, and several natural products (Oxytetracycline, Chlortetracycline, Demethylchlotetracycline) and a number of synthetic derivatives Semi-synthetic: Doxycycline, Minocycline - both are lipophilic and are absorbed completely in the GIT, thus less inhibitory for the normal gut flora - lesser cases of resistance

Inhibitors of the 50s Ribosomal subunit

Erythromycin Clindamycin and Lincomycin Fusidic acid Chloramphenicol Puromycin

ERYTHROMYCIN most important of the macrolide group, characterized by a presence of a macrocyclic lactone ring binds to the 50s ribosomal unit to inhibit peptide chain elongation during protein synthesis most frequently used antibiotic in patient allergic to penicillin primarily bacteriostatic, but may be bactericidal for some organism effective against gram (+) bacteria and few gram (-) org. treatment for Mycoplasma pneumonia, Legionella pneumophila, diptheria and pertussis

CHLORAMPHENICOL action is similar to erythromycin bacteriostatic for gram (+) and gram (-) bacteria including Rickettsia and Chlamydia maybe inactivated by the enzyme chloramphenicol acetyltransferase its use demand caution because its very toxic, can cause allergic & neurotoxic reaction used only in serious and life-threatening situation most common side effect is bone marrow depression leading to aplastic anemia and decreased blood leukocytes currently used in the treatment of H. influenza meningitis, Anaerobic infections and Typhoid Fever

 Clindamycin and Lincomycin - similar activity spectrum with Erythromycin but chemically unrelated - active against group A streptococcus, Pneumococci and Penicillinase producing staphylococci - Lincomycin - Clindamycin - is the chloroderivative of lincomycin and is superior to the parent compound in its activity and absorption properties greater activity against anaerobic bacteria, esp. B. fragilis infection as alternative to patients allergic to penicillin

 FUSIDIC ACID - steroidal antibiotic with narrow antibacterial spectrum - active against gram (+) bacteria - no significant activity against gram (-) organism - Fucidin (salt of fusidic acid) - used in the treatment of various serious staphylococcal infxn PUROMYCIN - not clinically useful but has an inhibiting effect on growth of both procaryotic and eucaryotic organism

Inhibitors of the Protein Assembly

GRISEOFULVIN a fungistatic agent specific for fungi whose cell wall contains chitin no effect on fungi with cellulose cell wall, on bacteria and yeast protoplast given orally clinically useful in treating chronic dermatophyte infection , for which it is the standard therapy after oral administration delivered on Stratum corneum via the sweat or by deposition in keratinocytes

Inhibitors of Tetrahydrofolate Synthesis

(Folic acid synthesis)
SULFONAMIDE

generic name for derivatives of para-aminobenzene sulfonamide or sulfanilamide MOA: interfere with synthesis of folic acid (required for the synthesis of purine & pyrimidine) precursor of RNA and DNA inhibitory activity against gram (+) and gram (-) organisms, Nocardia, Chlamydia, and certain protozoa ( Pneumocystis and Plasmodium) useful in the treatment of uncomplicated UTI caused by E. coli

Other analogues of Para-Aminobenzoic acid Sulfones analogue of PABA and is most useful clinically derivatives of the diaminodiphenylsulfone (dapsone) marked specificity against Mycobacteria primarily used to treat leprosy Para-aminosalicylic Acid (PAS) highly specific for Mycobacterium tuberculosis used primarily as a second-line drug in the treatment of tuberculosis

Inhibitors of dihydrofolate reductase

TRIMETHOPRIM antifolic acid agent very potent and a selective inhibitor of bacterial dihydrofolate reductase spectrum of activity similar to sulfonamide , including gram (+) cocci and gram (-) bacilli are bactericidal and act synergistically with sulfonamide sulfamethoxazole cotrimoxazol useful in the treatment of recurrent or chronic UTI and Pneumocystis infection also effective against bronchitis, shigellosis and Typhoid fever

Other metabolite analogues Flucytosine - flourine analogue of cytosine (5-Flourocytosine) - an antifungal agent which is a true antimetabolite - effective against most systemic deep-seated fungal infection - drug of choice for Chromomycosis - toxic effect: skin rashes, diarrhea, liver damage and aplastic anemia Isoniazid (INH) - hydrazide of isonicotinic acid - highly specific for Mycobacterium tuberculosis - hepatotoxic - most potent anti-TB drug - never given as single drug