Pharmacology/Therapeutics I Block III Lectures

2012‐2013

26. Introduction to Antibiotics & General Principles of Antimicrobial Therapy I – O’Keefe

27. Introduction to Antibiotics & General Principles of Antimicrobial Therapy II ‐ O’Keefe

28. Cell Wall Inhibitors I: Penicillins – O’Keefe

29. Cell Wall Inhibitors II: Cephalosporins, Carbapenems & Monobactams – O’Keefe

30. Cell Wall Inhibitors III: Vancomycin & Misc. Antibacterial Wall Agents – Reid

31. Fluoroquinolones & Metronidazole – Hecht

32. Protein Synthesis Inhibitors II: Tetracyclines & Chloramophenieol,… ‐ Reid

33. Protein Synthesis Inhibitors III: Macrolides, Clindamycin …. – Chauhan

34. Protein Synthesis Inhibitors I: Aminoglycosides – Pachucki

35. Heparin/Oral Anticoagulants – Moorman

36. Antiplatelet Drugs – Fareed

37. Thrombolytics ‐ Fareed S. Erdman/Jan 2011

SPECTRUM OF ACTIVITY SUMMARY CHART

Organism Penicillins Cephalosporins Carba Mono FQs Mac AGs Vanc Syner, Tets¶ Bact Col Clind Metro st £ PenG Naf Amp Una, Tic Pip Tim/ 1 2nd 3rd 4th Anti Imi, Mero Aztreo Cip Levo Ery, Gent, Linez, MRSA Erta, Dori Aug Zos Moxi Cla Tob,, Dapto Azi Amik Telav MSSA X X X X X X‡ X X X X X ?X X X X X X X MRSA X X X X X¶ X PSSP X X X X X X X X‡ X X X ?X X X X X X X PRSP X‡ X X ?X X X X Viridans Strep X X X X X X X X X‡ X X X ?X X X X X X X Group Strep X X X X X X X X X‡ X X X ?X X X X X X X Enterococcus X X X X X X ?X X X X*** E. faecalis (VRE) H. influenzae X§ X X X X X X X X X X X X X∞ X X X M. catarr X X X X X X X X X X∞ X Neisseria X X X X X X X X X X X X X X X E coli X X X X X X X X X X X X X X X X X Proteus X X X X X X X X X X X X X X X X Klebsiella X ?X X X X X X X X X X X X X X Enterobacter X X X X X X X X X X X X X Serratia X X X X X X X X X X X Salmonella X X X X X X X X X X X X X X X Pseudomonas X X X X† X X** X X X€ X X ADA X X X X X X X X ?X BDA X X X X* X ?X X C. difficile X X Legionella X X X X MSSA = Methicillin-Susceptible Staphylococcus aureus ADA = Above the Diaphragm Anaerobes MRSA = Methicillin-Resistant Staphylococcus aureus BDA = Below the Diaphragm Anaerobes, especially Bacteroides spp. PSSP = Penicillin-Susceptible Streptococcus pneumoniae PRSP = Penicillin-Resistant Streptococcus pneumoniae Una = Unasyn (ampicillin/sulbactam), Aug = Augmentin (amoxicillin/clavulanate) Tim/Zos = Timentin (ticarcillin/clavulanate) and Zosyn (piperacillin/tazobactam) § β-lactamase negative strains only ‡ Ceftriaxone and cefotaxime only † Ceftazidime and cefoperazone only * Cephamycin antibiotics including cefotetan and cefoxitin ** Not ertapenem £ Levofloxacin with better activity against gram-negatives €Not moxifloxacin ∞ Azithromycin and clarithromycin only ***Activity versus VRE (Synercid only vs VRE faecium; telavancin only against some VRE) - a TARGET organism ¶ Tigecycline with expanded coverage against gram-positive aerobes, gram-negative aerobes (except Proteus and Pseudomonas) and anaerobes

Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

#26-27 - INTRODUCTION TO ANTIBIOTICS

Appropriate antimicrobial therapy for a given infectious disease requires knowledge of the potential site of infection; the infecting pathogen(s); the expected activity of the antibiotic(s) against the infecting pathogen(s); and host characteristics. Therefore, appropriate diagnosis is crucial. Specimens should be obtained from the suspected site of infection (optimally BEFORE antibiotics are initiated) for microscopy and culture to try and identify the causative pathogen(s).

I. ESTABLISHING THE PRESENCE OF INFECTION – Before initiating antibiotic therapy, it is important to first clearly establish the presence of an infectious process. The isolation of an organism from a clinical specimen does not always indicate the presence of infection or mandate anti-infective therapy. A. NORMAL FLORA, CONTAMINATION, COLONIZATION, OR INFECTION 1. The human body harbors a number of microorganisms that colonize certain body systems called “normal flora”, which are normally harmless bacteria that occur naturally on the skin, and in the respiratory, gastrointestinal, and genitourinary tracts. a. Normal flora bacteria are located in anatomic sites where pathogenic organisms can cause disease. They often compete with pathogenic organisms for nutrients, stimulate cross-protective antibodies, and suppress the growth of pathogenic organisms. b. Bacteria that comprise normal flora may become pathogenic when host defenses are impaired or when they are translocated to sterile body sites during trauma, intravenous line insertion, or surgery (necessitating skin disinfection before line insertion or surgery). c. Indiscriminate use of antibiotics can alter or eradicate the protective normal bacterial flora. d. Patients who are hospitalized for more than 48 hours can have their usual normal flora replaced by the “normal flora” of the hospital, which tend to be gram-negative aerobes. e. SITES OF NORMAL FLORA COLONIZATION

SKIN UPPER RESPIRATORY TRACT Diphtheroids (Corynebacterium spp.) Bacteroides spp. Propionibacteriaceae Haemophilus spp. Bacillus spp. Neisseria spp. Staphylococci (esp. coagulase-negative) Streptococci (anaerobic) Streptococci GASTROINTESTINAL TRACT GENITOURINARY TRACT Bacteroides spp. Lactobacillus spp. Clostridium spp. Corynebacterium spp. Enterobacteriaceae (E. coli, Klebsiella spp.) Enterobacteriaceae – especially E.coli Streptococci (anaerobic) Staphylococci (S. saprophyticus) Enterococcus spp. Streptococci Fusobacterium spp.

1 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

2. BODY SITES THAT ARE STERILE include the bloodstream, cerebrospinal fluid, pleural fluid, peritoneal fluid, pericardial fluid, synovial fluid, bone, and urine (taken directly from the bladder). 3. The isolation of an organism from a clinical specimen does not always represent the presence of infection - clinicians must consider the clinical, laboratory and radiographic evidence available to differentiate between contamination, colonization, or infection. a. Contamination – an organism is introduced into the clinical specimen during the sample acquisition process i. Example: isolation of coagulase negative staphylococci in the blood of a patient where the blood was drawn via a peripheral stick and the patient does not have signs of infection (normal skin flora bacteria contaminated blood culture). b. Colonization – an organism is present at a body site but is not invading host tissue or eliciting host responses. i. Example: isolation of Pseudomonas aeruginosa from a sputum culture in a patient without fever, cough, or infiltrate on chest x-ray (pathogenic bacteria in patient without clinical/radiologic signs of pneumonia). c. Infection – a pathogenic organism is present at a body site and is damaging host tissues and eliciting host responses and symptoms consistent with infection. i. Example: isolation of Streptococcus pneumoniae in the cerebrospinal fluid of a patient with fever, headache, photophobia, and neck stiffness. 4. Clinical signs of infection (both localized and systemic) include:

LOCALIZED SYSTEMIC pain purulent discharge FEVER malaise inflammation sputum production chills, rigors hypotension swelling cough tachycardia mental status changes erythema abnormal discharge tachypnea

5. Laboratory signs suggestive of infection include: a. Elevated white blood cell count (peripheral {leukocytosis} and/or at site of infection) with a “left shift” b. Positive gram stain and culture c. Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) d. Positive antigen or antibody titers 6. Radiographic signs of infection a. Infiltrate on chest x-ray in patients with pneumonia b. Periosteal elevation and bony destruction on a bone x-ray in a patient with osteomyelitis 7. Assessment of the Severity of Infection a. The severity of a patient’s infection is based on the degree of abnormality in the parameters above.

2 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

b. Significant alterations in cardiac, respiratory and central nervous system parameters may signify a serious, life-threatening infection. c. The severity of infection may influence the choice, route of administration, and dose of antibiotics used. 8. Common Bacterial Pathogens by Site of Infection a. Certain bacteria have a propensity to commonly cause infection in particular body sites or fluids. b. This information is used to guide the choice of empiric antibiotic therapy before the results of the gram stain, culture, and susceptibility results are known. An antibiotic is empirically chosen that has a spectrum of activity that covers the most common causative bacteria at the patient’s suspected infection site.

SUSPECTED ORGANISMS BY SITE OF INFECTION Mouth Skin & Soft Tissue Bone & Joint Peptococcus Staphylococcus aureus Staphylococcus aureus Peptostreptococcus Staphylococcus epidermidis Staph epidermidis Actinomyces israelii Streptococcus pyogenes Neisseria gonorrhoeae Treponema pallidum Pasteurella multocida Streptococcus spp. Gram-negative bacilli Abdomen Urinary Tract Upper Respiratory Tract Escherichia coli Escherichia coli Streptococcus pneumoniae Proteus spp. Proteus mirabilis Haemophilus influenzae Klebsiella spp. Klebsiella spp. Moraxella catarrhalis Enterococci Enterococcus spp. Streptococcus pyogenes Bacteroides spp. Staphylococcus saprophyticus Fusobacterium spp. Lower Respiratory Tract Lower Resp Tract Meningitis Community-Acquired Hospital-Acquired Streptococcus pneumoniae Staphylococcus aureus (MRSA) Streptococcus pneumoniae Haemophilus influenzae Pseudomonas aeruginosa Neisseria meningitidis Klebsiella pneumoniae Acinetobacter sp. Klebsiella pneumoniae Enterobacter spp. Haemophilus influenzae Legionella pneumophila Citrobacter spp. Group B Strep Mycoplasma pneumoniae Serratia spp. Escherichia coli Chlamydophila pneumoniae Acinetobacter spp. Listeria monocytogenes Moraxella catarrhalis Staphylococcus aureus

When selecting an antibiotic for a particular infection, one of the issues that will be considered is the result of antimicrobial susceptibility testing of the infecting pathogen, which typically takes 24 to 48 hours or more to perform. If the susceptibility results of the infecting pathogen are not yet known, an antibiotic is empirically selected based on the most likely infecting organism and current local susceptibility patterns. In most cases, therapy must be initiated at the suspicion of infection since infectious diseases are often acute, and a delay in treatment may result in serious morbidity or even mortality (e.g., meningitis, pneumonia). Once the susceptibility results of the infecting bacteria are known, empiric antibiotic therapy should be streamlined to an antibiotic agent with more specific activity toward the infecting bacteria.

3 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

II. ANTIMICROBIAL SUSCEPTIBILITY TESTING

A. General Antimicrobial Spectrum of Activity - the spectrum of activity for each antibiotic is a general list of bacteria that the antibiotic displays activity against. However, since bacteria may become resistant to antibiotics over time, recent national, local, and specific organism susceptibility data should be considered when selecting an antibiotic to treat a specific patient’s infection. 1. Narrow Spectrum: the antibiotic has activity against a limited group of bacteria (e.g., penicillin has activity against some gram-positive and gram- negative cocci, but not gram-negative bacilli). 2. Broad Spectrum: the antibiotic has activity against a wide variety of bacteria, such as gram-positive and gram-negative bacteria (e.g., imipenem has activity against gram-positive and gram-negative aerobes and anaerobes).

B. Susceptibility Definitions 1. Minimum Inhibitory Concentration or MIC– the lowest concentration of an antibiotic that prevents visible growth (unaided eye) of a bacteria after 18 to 24 hours of incubation 2. Minimum Bactericidal Concentration or MBC – the lowest concentration of an antibiotic that results in a decrease of > 99.9% of the bacterial inoculum (MIC  MBC) 3. Susceptibility Breakpoints – interpretive guidelines established by the Clinical and Laboratory Standards Institute (CLSI) that categorize the MIC values or zone sizes for each antibiotics against each bacteria as: a. Susceptible (S) – organism will most likely be eradicated during treatment of infection using normal doses of the specified antibiotic; concentrations of the antibiotic represented by the MIC are easily achieved in patient’s serum with usual doses. b. Intermediate (I) – results are considered equivocal or indeterminate; MICs are higher, and treatment may be successful when maximum doses are used or if the drug concentrates at the site of infection. c. Resistant (R) – indicates less than optimal results are anticipated if the particular antibiotic is used; the MIC exceeds usual serum concentrations (even if maximal doses are used). d. The interpretive guidelines for S, I, and R of each antibiotic are often different because they are based on clinical PK of the individual drug (achievable serum and tissue concentrations), general activity of the antibiotic, site of infection, and data from clinical efficacy trials. e. Susceptibility breakpoints differ for each antimicrobial drug class and even between antibiotics within the same drug class – therefore, MIC values often cannot be compared between antibiotics.

C. TESTING METHODS FOR SUSCEPTIBILITY - once an organism is cultured in the microbiology lab, further testing is performed to determine the antibiotic susceptibility of the organism to serve as a guide to streamline antibiotic therapy. 1. Broth Dilution (macrodilution with test tubes, microdilution with automated microtiter plates or cassettes) – a quantitative determination of the in vitro activity of an antibiotic since an exact MIC or MIC range can be determined 4 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

a. Dilutions of an antibiotic (based on achievable serum concentrations after usual doses) are placed in broth with a standard inoculum of the infecting bacteria and incubated for 18 to 24 hours. b. MIC = the lowest concentration of an antibiotic that prevents visible growth of the infecting bacteria after 18 to 24 hours of incubation (clear to unaided eye with macrodilution; automated systems by the machine). c. Macrodilution testing employs two-fold serial dilutions of an antibiotic (based on achievable serum concentrations after usual doses) incubated in test tubes with a standard inoculum of the patient’s infecting bacteria; the exact MIC of the antibiotic is the first tube without visible growth; labor and resource intensive. i. MBC – lowest concentration of the antibiotic that kills bacteria  Test tubes without visible growth are cultured on agar plates, after incubation colonies counted - MBC is the concentration that reduced the original inoculum by 99.9% after 24 hours of incubation.  MBC is only determined in limited circumstances such as in the treatment of some infections where bactericidal activity may be more predictive of a favorable outcome (meningitis, endocarditis).

With permission from: A Practical Approach to Infectious Diseases, 4th edition, 1996, page955

d. Microdilution methods employ microtiter plates or cassettes that contain wells with serial dilutions of several antibiotics that can be tested for susceptibility simultaneously in an automated system. e. Size constraints of the plates or cassettes allow only a limited number of concentrations to be tested for each antibiotic (usually those representing the S, I, and R breakpoints), so that an MIC range may be reported instead of an exact MIC (for example  8 g/ml, susceptible). f. Automated microdilution systems are the most common method utilized in microbiology labs for susceptibility testing because less labor and resources are required for performance.

5 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

2. Disk Diffusion (Kirby Bauer Method) – a qualitative determination of the in vitro activity of an antibiotic a. Filter paper disks impregnated with a fixed concentration of an antibiotic are placed on agar plates inoculated with a standardized inoculum of the patient’s infecting bacteria. b. Bacteria multiply on the plate while antibiotic diffuses out of the disk; bacterial growth occurs only in areas where drug concentrations are below those required to cause inhibition of bacterial growth. c. A clear zone of inhibition is then observed around the disk - the larger the diameter, the more active the drug against the bacteria. Zone diameters in millimeters (mm) for each drug have been correlated to susceptible and resistant interpretations; however, exact MICs cannot be determined.

With permission from: Diagnostic Microbiology, 12th edition, 2007, page 195

3. E-Test (Epsilometer Test) – combines the quantitative benefits of microdilution with the ease of agar dilution a. A plastic strip impregnated with a known, prefixed concentration gradient of antibiotic is placed on an agar plate with a standardized inoculum of the patient’s infecting bacteria. b. Bacteria multiply on the agar plate while antibiotic diffuses out of the strip according to the concentration gradient; bacterial growth occurs only in areas where drug concentrations are below those required to cause inhibition of bacterial growth. c. An elliptical zone of inhibition is then formed, and the MIC is measured where the ellipse crosses the antibiotic strip. An exact MIC can be determined.

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With permission from: Diagnostic Microbiology, 12th edition, 2007, page 200

4. Susceptibility Reports a. For each patient’s infecting bacteria, a susceptibility report will be generated that lists the antibiotics that were tested for activity against the organism, the exact MIC or zone size (or MIC range if automated systems are used) and CLSI interpretation (S, I, and R). b. This information is utilized with other clinical and patient-specific parameters (to be discussed later) to select an antibiotic regimen for the treatment of the patient’s infection. 5. Hospital Antibiograms a. Susceptibility data from organisms cultured from patients (inpatients and/or outpatients) are compiled in an annual report called an Antibiogram. b. The susceptibility data in an antibiogram is typically used to help guide the choice of empiric antibiotic therapy before the infecting organism has been identified in the lab. Clinicians use the antibiogram to determine the most active antibiotic against specific organisms at that specific institution.

III. HOW ANTIBIOTICS ARE USED

A. The treatment of infectious diseases is quite different than other disease states requiring drug therapy in a number of ways: 1. Antibiotics can be used to treat a suspected or documented infection, or can be used to prevent an infection from occurring in high-risk patients. 7 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

2. Additionally, anti-infective therapy is typically given for a finite duration of therapy or a particular number of days based on previous clinical data for that infection type and/or infecting organism. Occasionally, some patients may receive anti-infective therapy for an infinite duration (such as that given for diabetes, CHF, or hypertension).

B. Empiric Therapy – Antibiotics are administered that have activity against the predicted or most likely pathogens causing a patient’s infection based on the signs and symptoms of infection. The site of infection may or may not be known, and the culture results are pending, negative, or unobtainable. 1. Examples – antibiotics are started in a patient with community-acquired pneumonia who is unable to expectorate a sputum sample; a patient presents to the hospital with signs of bacterial meningitis and antibiotics are started immediately after a lumbar puncture is performed. 2. The initial antibiotic therapy is selected based on the known or probable site of infection, the most likely causative organism(s), the drug of choice for that particular organism and infection, and the local (hospital antibiogram) or regional susceptibility patterns of the suspected bacterial pathogens. Empiric antibiotic therapy usually covers a wide variety of bacteria (broad-spectrum). 3. Empiric therapy is usually administered until the culture and susceptibility results are available. If an organism is not isolated, empiric therapy may be continued until the finite duration of antibiotic therapy has been completed for that infection type, assuming the patient is improving.

C. Directed or targeted therapy – antibiotics are used to treat an established infection where the site of infection, causative pathogen, and antibiotic susceptibilities are known. 1. Example – a patient has bacteremia with methicillin-susceptible Staphylococcus aureus and is receiving intravenous nafcillin therapy. 2. Antibiotic therapy is selected based upon the susceptibility results of the infecting pathogen, and is typically changed from the empiric antibiotic originally chosen to a more narrow-spectrum agent directed toward the infecting organism. 3. Antibiotics are given for the finite duration of therapy as determined by the infection type. All effective antibiotics that have been administered for the infection count toward the effective days of therapy (empiric and directed).

D. Prophylactic Therapy – antibiotics are given to prevent the development of infection during a procedure or immunocompromised state when there is a considerable risk of infection 1. Examples – a patient with damaged heart valves is given amoxicillin to prevent endocarditis at the time of a bacteremia-inducing dental procedure; an AIDS patient is given Bactrim to prevent Pneumocystis carinii pneumonia 3 when the CD4 count is less than 200 cells/mm ; antibiotics are given prior to surgical procedures to prevent surgical site infections 2. Antibiotic therapy is selected based on the local and regional susceptibility patterns of the most likely infecting bacteria.

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3. Prophylaxis is administered for as long as the patient is at risk, such as single dose antibiotic therapy for surgical/dental prophylaxis or longer durations of antibiotic therapy during immunosuppressive states.

E. Combination Therapy 1. Combination therapy may be selected in a limited number of circumstances for the treatment of infection: a. To provide coverage against all organisms in a mixed, polymicrobial infection where a single antibiotic does not cover all of the infecting organisms – used to broaden bacterial coverage. b. To take advantage of synergistic properties when the antibiotics are used together. c. To decrease the emergence of resistance – only for tuberculosis. 2. Synergy – the activity of the antimicrobial combination is greater than that expected from the additive activity of the individual antimicrobials a. (A + B) > A + B b. Example: ampicillin and gentamicin are administered together in the treatment of Enterococcal endocarditis in order to produce bactericidal activity and achieve successful eradication of the infection (alone each agent is bacteriostatic against Enterococcus) 3. Additive – the activity of the antimicrobial combination is no greater than the sum of the effects of each individual component (no greater and no worse) a. (A + B) = A + B 4. Antagonism – the activity of the antimicrobial combination is less than that expected from the additive activity of the individual antimicrobials a. (A + B) < A + B b. Example: azole antifungals and amphotericin B

IV. PHARMACODYNAMIC CONSIDERATIONS

A. Type of antibacterial activity – BACTERIOSTATIC or BACTERICIDAL? 1. Bacteriostatic – antimicrobial agents that inhibit the growth of susceptible bacteria and rely on host defenses to help kill the bacteria and subsequently eradicate the infection a. Typically, normal host defenses are required for clinical success of bacteriostatic agents, so they should be used with caution in patients who are immunocompromised. b. Examples: macrolides, ketolides, streptogramins, oxazolidinones, tetracyclines, glycylcyclines, sulfonamides (alone), and clindamycin 2. Bactericidal – antimicrobial agents that kill susceptible bacteria in the absence of host defenses a. Bactericidal activity is considered essential in the treatment of infections located in sites where host defenses are not adequate including the meninges (meningitis), heart valves (endocarditis), and bone (osteomyelitis); as well as in patients with impaired host defenses (febrile neutropenia). b. Examples: -lactams, aminoglycosides, vancomycin, daptomycin, fluoroquinolones, metronidazole, and trimethoprim-sulfamethoxazole

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B. Pharmacodynamics (PD) is the study of the time course or rate of bacterial killing relative to serum concentrations. The study of pharmacodynamic provides a rational basis for optimizing dosing regimens by describing the relationship between drug, host, and antimicrobial effect by integrating both pharmacokinetic and MIC data.

Concentration Pharmacolgic or versus time in tissue toxic effect Concentration and other body fluid Dosage versus time in Regimen serum Concentration Antimicrobial versus time at site effect versus time Absorption of infection Distribution Elimination

Pharmacokinetics Pharmacodynamics

C. PD studies have demonstrated marked differences in the time course of bacterial killing among different antibiotics, described by examining the relationship between pharmacokinetic parameters and the MIC.

D. On the basis of PD studies, antibiotics can generally be divided into 2 major groups on the basis of their bactericidal activity: 1. Concentration-dependent – the higher the serum concentration of the antibiotic, the more rapid and extensive the degree of bacterial killing. Concentration-dependent agents also appear to have prolonged persistent effects (post antibiotic effects or PAE) that allow for infrequent dosing. a. Examples of concentration-dependent antibiotics include the aminoglycosides, the fluoroquinolones, daptomycin, and metronidazole b. The major PD parameters that correlate with clinical and microbiologic outcome (efficacy) of concentration-dependent antibiotics are the Peak/MIC ratio and the AUC/MIC ratio. c. Goal of dosing - infrequent dosing of large doses to maximize drug concentrations or magnitude of exposure for optimal bacterial killing. 2. Concentration-independent (time-dependent) – higher serum concentrations of the antimicrobial do not produce enhanced bacterial killing. The extent of bacterial killing is largely dependent on the time of exposure. These agents are not rapidly bactericidal, and typically have a short or nonexistent PAE. a. Examples include the -lactams, clindamycin, macrolides, ketolides, vancomycin, tetracyclines, linezolid, Synercid b. Goal of dosing - optimize the duration of exposure (Time>MIC). Maintain the serum concentrations of the antibiotic above the MIC for the infecting pathogen for at least 40-70% of the dosing interval, depending on the organism.

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E. Post-Antibiotic Effect (PAE) – the time it takes for a bacteria to recover after exposure to an antibiotic, or the time it takes for bacteria to recover and begin regrowth after an antibiotic has been removed. 1. The exact duration of the PAE is drug and organism specific. 2. Agents with appreciable PAEs may be dosed to allow serum concentrations to fall below the MIC of the infecting bacteria since regrowth will not occur for a finite period (for as long as the antibiotic’s PAE). 3. All antibiotics produce some PAE against gram-positive bacteria; the PAE for -lactams is approximately 2 hours. 4. For gram-negative bacteria, prolonged PAEs are observed after exposure to protein synthesis inhibitors or nucleic acid synthesis inhibitors (fluoroquinolones and aminoglycosides); -lactams have short or nonexistent PAE.

V. ANTIMICROBIAL REGIMEN SELECTION

A. Choosing an antibiotic to treat a patient’s infection is more complicated than simply matching a drug to a known or suspected pathogen. The decision is typically based on the interrelationship between the patient, the infection, and the characteristics of the antibiotic.

B. When selecting an antibiotic for the treatment of an infection, a variety of factors must be considered: 1. Infection-Specific Factors a. Severity of infection (mild. moderate, severe, life-threatening) – influences the route of administration, dose, number of antibiotics Oral – for infections that are mild, or for those that are significantly improved and can be treated on an outpatient basis IV – used for infections that are serious or life-threatening, or for antibiotics with insufficient absorption from the GI tract. b. Site of infection – influences the antibiotic and dose, since adequate concentrations of the drug must reach the site of infection for efficacy. Special considerations must be made for the treatment of meningitis (cross blood-brain barrier), endocarditis, prostatitis, etc. c. Infecting organism – site of acquisition of the infection (community versus hospital, nursing home); exposure to ill family members, pets; employment; recent travel; known or anticipated susceptibility patterns; empiric versus directed therapy; drug of choice for particular organism/infection; need for combination therapy 2. Host Factors – patient-specific characteristics should be considered in every patient in whom antimicrobial therapy will be instituted a. Allergies – careful assessment of allergy history should be performed to ascertain the potential antimicrobial agents that may be used for a patient’s infection. i. A careful allergy history is necessary because many patients confuse common adverse effects with true allergic reactions (GI effects such as nausea, vomiting, or diarrhea).

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ii. The most common antibiotic allergy is to the penicillins; must consider the allergic reaction as well as the degree of cross- reactivity to other -lactam antimicrobials. iii. Allergy to a specific antibiotic precludes the use of that antibiotic (and often antibiotic class) for the treatment of infection. Typically, allergy to one macrolide precludes the use of other macrolides, and the same holds true for other antibiotics among the same class. b. Age – aids in identification of the causative pathogen, as well as assessing the patient’s ability to eliminate antimicrobial agents. i. The causative pathogen in meningitis varies markedly depending on the age of the patient. ii. The pharmacokinetics (PK) of different antibiotics may be altered based on the age of the patient including protein binding, metabolism, or renal elimination of an antimicrobial agent, which may influence drug selection or drug dosing.  Premature neonates develop kernicterus from sulfonamides due to displacement of bilirubin from albumin.  Renal function (and elimination) declines with age.  Age-related hepatotoxicity with isoniazid. c. Pregnancy and nursing – the fetus is at risk for teratogenicity during pregnancy and adverse effects while nursing during antibiotic therapy with some agents. Also, PK parameters are altered during pregnancy (increased volume of distribution and clearance for some drugs) and must be taken into account when dosing. d. Renal and hepatic function – patients with diminished renal or hepatic function will accumulate certain anti-infectives, which may lead to undue toxicity. Dosage adjustments are necessary ensure efficacy but avoid undue toxicity. i. Antibiotics primarily eliminated by the kidney include most - lactams (except nafcillin, oxacillin, ceftriaxone, cefoperazone); most fluoroquinolones, clarithromycin, aminoglycosides, vancomycin, daptomycin, Bactrim, and tetracycline. Dosages can be adjusted according to predetermined guidelines. ii. Some antibiotics may be removed during a hemodialysis session and require supplemental dosing. iii. Liver dysfunction will alter the elimination of chloramphenicol, clindamycin, metronidazole, nafcillin/oxacillin, linezolid, Synercid, erythromycin, azithromycin, doxycycline, tigecycline, and Bactrim. Dosage adjustments in this setting are not well-studied. e. Concomitant drug therapy may influence the antibiotic used, the dose, or monitoring (occurrence of a drug-drug interactions) i. Augmented toxicity – coadministration of drugs may increase the likelihood of toxicity (vancomycin and gentamicin  nephrotoxicity; ganciclovir and zidovudine  neutropenia) ii. Altered PK – coadministration may alter the A, D, M, and E of either agent (divalent cations decrease the absorption of fluoro- 12 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

quinolones and tetracyclines   concentrations and treatment failure) f. Underlying disease states influence antibiotic selection by predisposing the patient to certain infections or particular causative pathogens related to their disease state. i. Patients with diabetes or peripheral vascular disease are prone to soft tissue infections of the lower extremities; patients with chronic lung disease are prone to pulmonary infections. ii. Underlying immunosuppression (malignancy, acquired immunodeficiencies) may lead to a wide variety of infections due to a number of etiologic agents. iii. Disruption of integumentary barriers from burns, trauma, or iatrogenic wounds (surgery, intravascular lines) may increase the risk of infection. 3. Drug Factors – the individual characteristics of each antibiotic must be considered when selecting the most appropriate agent a. In vitro spectrum of activity and current susceptibilities – antibiogram, national, regional, or local b. Clinical efficacy as demonstrated by FDA-approved indications or other clinical studies in the published literature c. Drug of choice charts – textbooks, treatment guidelines; the drug of choice for a specific infection is often based on the in vitro activity against the causative organisms, documented clinical efficacy of the agent against the causative organisms, PK properties of the drug (adequate concentration at site of infection), patient characteristics, etc d. Dosage forms available – oral (tablet, capsule, suspension), parenteral (intramuscular, intravenous), intrathecal i. The route of administration depends on the severity of illness of the patient (patient with hypotension should not receive oral therapy due to unreliable drug absorption); the age of the patient (can the patient swallow a tablet?); available dosage forms; etc. ii. Antibiotics that are only available orally should not be used for the treatment of meningitis e. Pharmacokinetics (tissue penetration, route of elimination) - choose an anti-infective that achieves adequate concentrations in the serum and the site of infection (with meningitis – agent must cross the blood brain barrier, etc.).

f. Pharmacodynamics i. What type of activity is required to treat the patient’s infection - bacteriostatic or bactericidal? ii. Consideration should be given to the type of bactericidal activity (concentration-dependent or time-dependent) the antibiotic provides and use this information to select an appropriate dose.

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g. Side effect profiles - the potential adverse events associated with the use of each antibiotic must be carefully considered for each patient i. Nephrotoxic agents should be used with caution (e.g., aminoglycosides, amphotericin) in patients with underlying renal insufficiency. h. Cost – antimicrobial agents are a major portion of hospital drug expenditures, and include more than just the obvious acquisition cost of the drug. Other considerations include the ancillary costs (preparation, storage, distribution, and administration of the drug), cost of frequent dosing, and the costs associated with monitoring and managing toxicity or serious adverse effects.

14 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

APPENDIX A: CLINICALLY-RELEVANT BACTERIA

GRAM-POSITIVE AEROBES GRAM-NEGATIVE AEROBES

Gram-positive cocci in clusters Gram-negative cocci Staphylococcus aureus Moraxella catarrhalis Staphylococcus epidermidis Neisseria meningitidis Staphylococcus saprophyticus Neisseria gonorrhoeae Staphylococcus haemolyticus Gram-negative coccobacilli Staphylococcus hominis Haemophilus influenzae Staphylococcus capitis Haemophilus parainfluenzae Staphylococcus saccharolyticus Gram-negative bacilli Gram-positive cocci in pairs Enterobacteriaceae Streptococcus pneumoniae Citrobacter freundii Gram-positive cocci in chains Enterobacter aerogenes or cloacae Group Streptococcus Escherichia coli Group A Strep - Streptococcus pyogenes Klebsiella pneumoniae Group B Strep - Streptococcus agalactiae Morganella morganii Group C Strep - Streptococcus equi Proteus mirabilis or vulgaris Group D Strep – S bovis, S. equinus Providencia spp Group F, G Strep Salmonella spp. Viridans Streptococcus Shigella spp. Streptococcus mitis Serratia marcescens Streptococcus milleri Yersinia pestis Streptococcus mutans Streptococcus sanguis Non-Enterobacteriaceae Streptococcus salivarius Acinetobacter spp Streptococcus intermedius Aeromonas hydrophila Gram-positive cocci in pairs AND chains Bordetella pertussis Enterococcus faecalis Burkholderia cepacia Enterococcus faecium Campylobacter jejuni Enterococcus gallinarum Gardnerella vaginalis Enterococcus casseliflavus Helicobacter pylori Gram-Positive BACILLI Pasteurella multocida Bacillus anthracis Pseudomonas aeruginosa Bacillus cereus Stenotrophomonas maltophilia Corynebacterium diphtheriae Vibrio cholerae Corynebacterium jeikeium Lactobacillus spp. Listeria monocytogenes Nocardia asteroides Streptomyces spp.

ANAEROBES 15 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

“Above the Diaphragm”

Gram-positive cocci Gram-negative cocci Gram-positive bacilli

Peptococcus Prevotella Actinomyces israelii Peptostreptococcus Veillonella Prevotella Porphyromonas Fusobacterium

“Below the Diaphragm”

Gram-positive bacilli Gram-negative bacilli

Clostridium perfringens Bacteroides fragilis Clostridium difficile Bacteroides fragilis group {“DOT” = distasonis, ovatus, thetaiotamicron) Clostridium tetani Fusobacterium spp. Prevotella

“Skin Anaerobes” Propionibacterium acnes (a gram-positive bacilli)

ATYPICAL BACTERIA Chlamydophila pneumoniae Chlamydia trachomatis Legionella pneumophila Mycoplasma pneumoniae

SPIROCHETES Treponema pallidum (syphilis) Borrelia burgdorferi (Lyme disease) Leptospira interrogans

16 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

APPENDIX B: ANTIBIOTIC CLASS SUMMARY

Class Group/ Name Static or Cidal CELL WALL SYNTHESIS INHIBITORS -Lactams Penicillins Bactericidal Cephalosporins Bactericidal Carbapenems Bactericidal Monobactams (aztreonam) Bactericidal -lactam inhibitor combos (Zosyn, Unasyn) Bactericidal Glycopeptides Vancomycin Bactericidal Lipopeptides* Daptomycin Bactericidal PROTEIN SYNTHESIS INHIBITORS Aminoglycosides* Gentamicin, tobramycin, amikacin Bactericidal Macrolides Erythromycin, azithromycin, clarithromycin Bacteriostatic Tetracyclines, Glycylcyclines Doxycycline, tetracycline, tigecycline Bacteriostatic Chloramphenicol Bacteriostatic Lincosamides Clindamycin Bacteriostatic Streptogramins Quinupristin/ dalfopristin (Synercid) Bacteriostatic Oxazolidinones Linezolid Bacteriostatic NUCLEIC ACID SYNTHESIS INHIBITORS Fluoroquinolones* Ciprofloxacin, levofloxacin, moxifloxacin Bactericidal Metronidazole* Bactericidal METABOLIC INHIBITORS Sulfonamides Trimethoprim-sulfamethoxazole Bactericidal

* Concentration-dependent bactericidal activity

17 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

#28 - PENICILLINS

Date: October 16, 2012, 10:00 – 11:00 AM

Suggested Reading: Wright AJ. The penicillins. Mayo Clinic Proceedings 1999;74:290-307.

Learning Objectives:

Beta-Lactams 1. Explain the differences in the chemical structure between the penicillins, cephalosporins, carbapenems, and monobactams. 2. Describe the general characteristics of -lactam antibiotics including their mechanism of action, mechanisms of resistance, pharmacodynamic properties, elimination half-life, route of elimination, and potential for cross-allergenicity.

Penicillins 1. Describe the differences in the spectrum of activity between the natural penicillins, the penicillinase-resistant penicillins, the aminopenicillins, the carboxypenicillins, the ureidopenicillins, and the -lactamase inhibitor combinations with special emphasis on the specific penicillin agents that have activity against Staphylococcus aureus, Pseudomonas aeruginosa, and Bacteroides fragilis. List examples of commonly used agents within each of the penicillin classes. 2. Describe the distribution characteristics of the penicillins into the cerebrospinal fluid, urinary tract, lungs, skin/soft tissue, and bone. List the penicillins that are not primarily eliminated by the kidneys. List the penicillins that require dosage adjustment in renal insufficiency, and those that are removed by hemodialysis. 3. List the penicillins that should be used with caution in patients with congestive heart failure (CHF) or renal failure due to the sodium load associated with their parenteral formulations. List the parenteral penicillin agent that has the most mEq of sodium per gram. 4. Discuss the main clinical uses of representative penicillins within each group of penicillins. 5. Describe the major adverse effects associated with the penicillin antibiotics. List the penicillins that are most likely to cause interstitial nephritis.

Drugs Covered in this Lecture:

Natural Penicillins: Aqueous Penicillin G, Benzathine Penicillin, Procaine Penicillin G, Penicillin VK Penicillinase-Resistant Penicillins: Nafcillin, Oxacillin, Dicloxacillin Aminopenicillins: Ampicillin, Amoxicillin Carboxypenicillins: Ticarcillin Ureidopenicillins: Piperacillin β-Lactamase Inhibitor Combinations: Ampicillin-Sulbactam (Unasyn), Amoxicillin-Clavulanate (Augmentin Piperacillin-Tazobactam (Zosyn)

1 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

-LACTAMS (Penicillins, Cephalosporins, Carbapenems, Monobactams)

Six General Characteristics of -Lactam Antibiotics (with a few exceptions)

1. Same mechanism of action - inhibitors of cell wall synthesis

2. Same mechanisms of resistance – destruction by β-lactamase enzymes; alteration in penicillin binding proteins (PBPs); decreased permeability of outer cell membrane in gram-negative bacteria

3. Pharmacodynamic properties – time-dependent bactericidal activity (except against Enterococcus spp.)

4. Short elimination half-life (< 2 hours) - repeated, frequent dosing is needed for most agents to maintain serum concentrations above the MIC of the infecting bacteria for an adequate amount of time (except ceftriaxone, cefoperazone, cefotetan, cefixime, ertapenem)

5. Renal elimination – primarily eliminated unchanged by glomerular filtration and tubular secretion (except nafcillin, oxacillin, ceftriaxone, cefoperazone)

6. Cross-allergenicity - all except aztreonam

#51 - PENICILLINS

I. INTRODUCTION

In 1929, penicillin was accidentally discovered by Dr. Alexander Fleming when he noted the antibacterial activity of a mold, Penicillium notatum, that was contaminating bacterial culture plates in his laboratory. Due to difficulties with purification and production, penicillin was not used in the treatment of infections until 1941 when it was utilized in the treatment of staphylococcal and streptococcal infections in seriously ill patients. Throughout the years, natural penicillin has remained a useful antibiotic for some of the bacteria for which it was initially introduced. The emergence of bacteria resistant to natural penicillin, as well as the need for agents with expanded antibacterial activity, led to the development of several groups of semisynthetic penicillins with varying side chains to enhance antibacterial activity and improve pharmacologic activity.

II. CHEMISTRY

A. All penicillins share the basic structure of a 5-membered thiazolidine ring connected to a - lactam ring, with attached acyl side chains.

B. Manipulations of the side chain have led to agents with differing antibacterial spectrums, greater -lactamase stability, and pharmacokinetic properties.

C. Bacterial -lactamase enzymes may hydrolytically attack the -lactam ring and render the penicillin inactive.

2 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

A = thiazolidine ring, B = β-lactam ring, C = acyl side chain

III. MECHANISM OF ACTION

A. Penicillins interfere with bacterial cell wall synthesis by binding to and inhibiting enzymes called penicillin-binding proteins (PBPs) that are located in the cell wall of bacteria.

B. PBPs are enzymes (transpeptidases, carboxypeptidases, and endopeptidases) that regulate the synthesis, assembly, and maintenance of peptidoglycan (cross-linking of the cell wall). The number, type, and location of PBPs vary between bacteria.

C. Inhibition of PBPs by -lactam antibiotics leads to inhibition of the final transpeptidation step of peptidoglycan synthesis, exposing a less osmotically stable cell membrane that leads to decreased bacterial growth, bacterial cell lysis, and death.

D. Penicillins, like all -lactam antibiotics, are bactericidal, except against Enterococcus spp. where they display bacteriostatic activity.

IV. MECHANISMS OF RESISTANCE

A. There are 3 primary mechanisms of resistance to penicillin antibiotics

1. Production of -lactamase enzymes

a. The most important and most common mechanism of bacterial resistance where the bacteria produces a -lactamase enzyme that hydrolyzes the cyclic amide bond of the -lactam ring, inactivating the antibiotic.

b. Over 100 different -lactamase enzymes have been identified. -lactamase enzymes may be plasmid-mediated or chromosomally-mediated, constitutive or inducible.

c. Produced by many gram-negative (H. influenzae, N. gonorrhoeae, M. catarrhalis, K. pneumoniae, E. coli, Proteus spp., P. aeruginosa, S. marcescens, etc.), some gram-positive (Staphylococcus aureus), and some anaerobic (Bacteroides fragilis) bacteria.

3 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

i. -lactamase enzymes produced by gram-negative bacteria reside in the periplasmic space (very efficient).

d. -lactamase inhibitors have been developed and combined with some penicillin agents to prevent the -lactamase enzymes of some bacteria from hydrolyzing the penicillin.

2. Alteration in the structure of the PBPs, which leads to decreased binding affinity of penicillins to the PBPs (e.g., methicillin-resistant Staphylococcus aureus, penicillin- resistant Streptococcus pneumoniae).

3. Inability of the antibiotic to reach the PBP target due to poor penetration through the outer membrane of the bacteria (gram-negative).

V. CLASSIFICATION AND SPECTRUM OF ACTIVITY

A. There are several groups of natural and semisynthetic penicillins currently available that have different spectrums of antibacterial activity. The different groups of semisynthetic penicillins were developed to provide extended antibacterial activity, including coverage against bacteria resistant to previous groups of penicillins.

B. Natural Penicillins - The first agents in the penicillin class to be used clinically. Examples of natural penicillins include aqueous penicillin G, benzathine penicillin G, procaine penicillin G, penicillin VK.

1. Gram-Positive: excellent activity against non--lactamase-producing gram- positive cocci and bacilli  Group Streptococci (groups A, B, C, F, G)  Viridans streptococci  Some Enterococcus spp.  Some Streptococcus pneumoniae (high level resistance ~ 15 to 20%)  Very little activity against Staphylococcus spp.- due to penicillinase production  Bacillus spp. (including B. anthracis)  Corynebacterium spp.

2. Gram-Negative: only against some gram-negative cocci  Neisseria meningitidis, non--lactamase-producing Neisseria gonorrhoeae, Pasteurella multocida

3. Anaerobes: good activity against gram-positive anaerobes  Mouth anaerobes (gram-positive cocci, “above the diaphragm”) – such as Peptococcus spp, Peptostreptococcus spp.  Clostridium spp. (gram-positive bacilli, “below the diaphragm”), with the exception of C. difficile

4 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

4. Other  Treponema pallidum, Actinomyces spp.

Penicillin G is still considered to be a DRUG OF CHOICE for the treatment of infections due to Treponema pallidum (syphilis), Neisseria meningitidis, Corynebacterium diphtheriae, Bacillus anthracis (anthrax), Clostridium perfringens and tetani, viridans and Group Streptococci.

C. Penicillinase-Resistant Penicillins - Developed to address the emergence of penicillinase-producing staphylococci that rendered the natural penicillins inactive. They contain an acyl side chain that sterically inhibits the action of penicillinase by preventing opening of the -lactam ring. Examples include nafcillin, methicillin, oxacillin, cloxacillin, and dicloxacillin.

1. Gram-Positive  Methicillin Susceptible Staphylococcus aureus (MSSA) - NOT ACTIVE AGAINST MRSA  Viridans and Group streptococci (less activity than Pen G)  No activity against Enterococcus spp. or S. pneumoniae

2. Gram-Negative: no activity

3. Anaerobes: limited

D. Aminopenicillins - Developed to address the need for penicillins with extended activity against gram-negative aerobic bacilli. Aminopenicillins were formulated by the addition of an amino group to the basic penicillin molecule. Examples include ampicillin and amoxicillin.

1. Gram-Positive: similar activity to the natural penicillins (also ineffective against Staphylococcus aureus because destroyed by penicillinase)  Better activity than natural penicillin against Enterococcus spp.  Excellent against Listeria monocytogenes, a gram-positive bacillus

2. Gram-Negative: better activity than natural penicillins  H. influenzae (only -lactamase negative strains  70%)  E.coli (45 to 50% of strains are resistant)  Proteus mirabilis  Salmonella spp., Shigella spp.

3. Anaerobes: activity similar to Pen G

Drug of Choice for infections due to Listeria monocytogenes, Enterococcus

5 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

E. Carboxypenicillins – Developed to address the emergence of more resistant gram-negative bacteria and the increasing frequency of Pseudomonas aeruginosa as a nosocomial pathogen. These agents were formulated by adding a carboxyl group to the basic penicillin molecule. Examples include carbenicillin and ticarcillin.

1. Gram-Positive: generally weak activity  Less active against Streptococcus spp.  Not active against. Enterococcus or Staphylococcus spp.

2. Gram-Negative: enhanced activity  Same gram-negative bacteria as aminopenicillins (including indole-positive Proteus mirabilis)  Enterobacter spp.  Providencia spp.  Morganella spp.  Pseudomonas aeruginosa

** NOT active against Klebsiella spp. or Serratia spp.

F. Ureidopenicillins – Developed to further enhance activity against gram-negative bacteria. These agents are derived from the ampicillin molecule with acyl side chain adaptations that allow for greater cell wall penetration and increased PBP affinity. The ureidopenicillins are the most broad-spectrum penicillins available without -lactamase inhibitors. Examples include mezlocillin, azlocillin, and piperacillin.

1. Gram-Positive  Good activity against viridans and Group Streptococci  Some activity against Enterococcus spp.  No activity against Staphylococcus spp.

2. Gram-Negative: improved activity  Displays activity against most Enterobacteriaceae  Active against Klebsiella spp. and Serratia marcescens  Pseudomonas aeruginosa (piperacillin is the most active penicillin)

3. Anaerobes:  Activity similar to Pen G against Clostridium and Peptostreptococcus  Some activity against Bacteroides fragilis

6 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

G. -lactamase Inhibitor Combinations: Available as a combination product containing a penicillin and a -lactamase inhibitor. The -lactamase inhibitor irreversibly binds to the catalytic site of the -lactamase enzyme, preventing the hydrolytic action on the penicillin. The -lactamase inhibitors enhance the antibacterial activity of their companion penicillin in situations where the resistance is primarily the result of -lactamase production. Examples: Amoxicillin / Clavulanic Acid (Augmentin) – PO Ampicillin / Sulbactam (Unasyn) – IV Ticarcillin / Clavulanic Acid (Timentin) – IV Piperacillin / Tazobactam (Zosyn) – IV

1. These combination agents will retain the same activity of the parent penicillin against non -lactamase producing organisms, and will have enhanced activity against -lactamase producing bacteria.

2. Gram-Positive  Provide activity against -lactamase producing strains of Staphylococcus aureus (they have activity against MSSA).

3. Gram-Negative  Enhanced activity against -lactamase producing strains of E. coli, Proteus spp., Klebsiella spp., H. influenzae, M. catarrhalis, and N. gonorrhoeae.  Not very active against the inducible -lactamase enzymes produced by Serratia marcescens, P. aeruginosa, indole-positive Proteus spp., Citrobacter spp., and Enterobacter spp. (SPICE bacteria).

4. Anaerobes  Enhanced activity against -lactamase producing strains of B. fragilis and B. fragilis group (DOT) organisms.

VI. PHARMACOLOGY

A. Pharmacodynamic principles of dosing

1. Penicillins display time-dependent bactericidal activity.

2. The pharmacodynamic parameter that correlates with clinical efficacy of the penicillins is Time above the MIC.

3. PAE for gram-positive bacteria; no significant PAE for gram-negatives.

4. Penicillins are bactericidal, but only display bacteriostatic activity against Enterococcus spp. Bactericidal activity (synergy) can be achieved against Enterococcus spp. by adding an aminoglycoside (gentamicin or streptomycin), which is used in the treatment of Enterococcal endocarditis.

7 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

B. General pharmacologic properties of the penicillins (see PK charts pages 9 and 10)

1. Absorption

a. Many penicillins are degraded by gastric acid and are unsuitable for oral administration, so they must be administered parenterally.

b. Orally-available penicillins are variably absorbed from the gastrointestinal tract (see PK charts). Concentrations achieved with oral dosing are lower than those achieved with parenteral dosing, so oral therapy should only be used for mild to moderate infections. Food typically delays the rate and/or extent of absorption.

c. Special Absorption Considerations i. Natural penicillins – oral pen G is poorly absorbed so that phenoxymethyl penicillin is used orally (pen VK); IM benzathine and procaine penicillin G are formulated to delay absorption resulting in prolonged serum and tissue concentrations ii. Aminopenicillins – amoxicillin displays higher bioavailability than ampicillin; food delays ampicillin absorption iii. Penicillinase-Resistant Penicillins – oral dicloxacillin displays the best bioavailability iv. Extended Spectrum Penicillins – carbenicillin available orally but with low bioavailability (30-40%); used for UTIs only

2. Distribution

a. Penicillins are widely distributed into body tissues and fluids including pleural fluid, synovial fluid, bone, bile, placenta, and pericardial fluid, but do NOT penetrate the eye or prostate. The variation in distribution of various penicillins depends on their molecular configuration and protein binding.

b. Adequate concentrations of penicillins in the cerebrospinal fluid (CSF) are attainable only in the presence of inflamed meninges when high doses of parenteral penicillins are used.

c. Penicillin binding to serum proteins is variable, ranging from 15% for the aminopenicillins to 97% for dicloxacillin. 3. Elimination

a. Most penicillins are eliminated primarily by the kidneys unchanged via glomerular filtration and tubular secretion, and require dosage adjustment in the presence of renal insufficiency. Exceptions include nafcillin and oxacillin, which are eliminated primarily by the liver, and piperacillin which undergoes dual elimination. b. Probenecid blocks the tubular secretion of renally-eliminated penicillins and can increase their serum concentrations.

8 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

c. Most penicillins are removed during hemodialysis or peritoneal dialysis, and require supplemental dosing after a hemodialysis procedure – the exceptions are nafcillin and oxacillin.

d. ALL penicillins have relatively short elimination half-lives (< 2 hours) and require repeated daily dosing (4 to 6 times daily) or continuous infusion to maintain therapeutic serum concentrations.

4. Other Pharmacologic Considerations

a. Sodium Load – several parenterally-administered penicillins (especially the carboxy- and ureidopenicillins) contain sodium in their parenteral preparations, which must be considered in patients with cardiac or renal dysfunction.

 Aqueous Sodium Penicillin G contains 2.0 mEq per 1 million units  Carbenicillin contains 4.7 mEq per gram  Ticarcillin contains 5.2 mEq per gram (also in Timentin)  Piperacillin contains 1.85 mEq per gram (also in Zosyn)

Table: Pharmacokinetic Characteristics of Natural Penicillins, Aminopenicillins, and Penicillinase- Resistant Penicillins

Drug F (%) Protein Half-life Route of Removal Dosing Route of Binding (hours) Excretion by HD Change Admin For RI Penicillin G -- 45-68 0.5 Renal Yes Yes IM, IV Penicillin V 60-73 75-89 0.5 Renal Yes Yes Oral Ampicillin 30-55 15-25 0.7-1.4 Renal Yes Yes Oral, IV, IM Amp/sulb -- 15-25 0.7-1.4 Renal Yes Yes IV Amoxicillin 75-90 17-20 0.7-1.4 Renal Yes Yes Oral Amox/clav 75-90 17-20 0.7-1.4 Renal Yes Yes Oral Dicloxacillin 35-76 95-97 0.3-0.9 Renal, some Minimal No Oral hepatic Nafcillin -- 70-90 0.5-1.5 Hepatic Minimal No IV, IM Oxacillin 30-35 89-94 0.3-0.9 Hepatic Minimal No Oral, IV, IM F = bioavailability HD = hemodialysis RI = renal insufficiency IV = intravenous IM = intramuscular

9 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

Table: Pharmacokinetic Characteristics of Carboxypenicillins and Ureidopenicillins

Drug Sodium Protein Half-life Route of Removal Dosing Route of Content Binding (hours) Excretion by HD Change Admin (mEq/g) For RI Carbenicillin 4.7 50-60 1.1 Renal Yes Yes Oral, IM, IV Ticarcillin 5.2 50-60 1.2 Renal Yes Yes IV Ticar/clav 5.2 50-60 1.2 Renal Yes Yes IV Piperacillin 1.85 15-20 1.0 Renal and Yes Yes IV hepatic Pip/tazo 1.85 15-20 1.0 Renal and Yes Yes IV hepatic HD = hemodialysis RI = renal insufficiency IV = intravenous IM = intramuscular

VII. CLINICAL USES

A. Natural Penicillins

1. Intravenous aqueous penicillin G is often used for serious infections in hospitalized patients due to its rapid effect and high serum concentrations. Lower serum concentrations are achieved with oral penicillin VK so that its use is limited to the treatment of mild to moderate infections such as pharyngitis or prophylaxis in some circumstances.

2. Considered to be a drug of choice for infections due to:

a. S. pneumoniae (IV or IM – for penicillin-susceptible or penicillin-intermediate strains)

b. Other Streptococci, including S. pyogenes (benzathine pen or aqueous pen), viridans streptococci pharyngitis (PO or IM); bacteremia, endocarditis (with an aminoglycoside), meningitis (IV)

c. Neisseria meningitidis - meningitis, meningococcemia (IV)

d. Treponema pallidum – syphilis (benzathine pen or IV pen)

e. Clostridium perfringens or tetani

f. Actinomycosis

10 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

3. Other Uses:

a. Endocarditis prophylaxis in patients with valvular heart disease undergoing dental procedures at high risk for inducing bacteremia

b. Prevention of rheumatic fever

B. Penicillinase-Resistant Penicillins (Antistaphylococcal Penicillins)

1. Because of enhanced activity against S. aureus, these agents are useful for the treatment of infections due to methicillin-susceptible Staphylococcus aureus (MSSA) such as skin and soft tissue infections, septic arthritis, osteomyelitis, bacteremia, endocarditis, etc. Parenteral therapy should be used for moderate to severe infections.

2. Oral dicloxacillin is useful for the treatment of mild to moderate skin and soft tissue infections, and as follow-up therapy after parenteral therapy for the treatment of more serious infections such as osteomyelitis or septic arthritis.

C. Aminopenicillins

1. Because of activity against respiratory tract pathogens, oral ampicillin and amoxicillin are useful for the treatment of mild to moderate pharyngitis, sinusitis, bronchitis, and otitis media.

2. Oral ampicillin or amoxicillin are useful for uncomplicated urinary tract infections due to susceptible organisms.

3. Parenteral ampicillin is used for the treatment of Enterococcal infections (with an aminoglycoside for endocarditis) and Listeria monocytogenes meningitis.

4. Endocarditis prophylaxis in patients with valvular heart disease.

5. Treatment of Salmonella (amoxicillin) and Shigella (ampicillin).

D. Carboxypenicillins and Ureidopenicillins

1. Due to enhanced activity against gram-negative bacteria, these agents are useful for the treatment of serious infections such as bacteremia, pneumonia, complicated urinary tract infection, peritonitis, intraabdominal infections, skin and soft tissue infections, bone and joint infections, and meningitis caused by gram-negative bacteria (hospital- acquired infections). Piperacillin is the most active penicillin for infections due to Pseudomonas aeruginosa.

2. May be used as empiric therapy in immunocompromised patients.

11 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

E. β-Lactamase Inhibitor Combination Products – enhanced activity against -lactamase- producing bacteria

1. Amoxicillin-clavulanate (Augmentin - PO) is useful for the treatment of otitis media, sinusitis, bronchitis, lower respiratory tract infections, and human or animal bites

2. Due to expanded activity against gram-positive and gram-negative bacteria (including anaerobes), the parenteral combination agents are often utilized in the treatment of polymicrobial infections such as intraabdominal infections, gynecological infections, diabetic foot infections, etc.

a. Ampicillin-sulbactam (Unasyn® – IV) is useful for the treatment of mixed aerobic/anaerobic infections (limited gram-negative coverage).

b. Piperacillin-tazobactam (Zosyn® – IV) is useful for the treatment of polymicrobial infections or other infections involving gram-negative bacteria including hospital- acquired pneumonia, bacteremia, complicated urinary tract infections, complicated skin and soft tissue infections, intraabdominal infections, and empiric therapy for febrile neutropenia.

VIII. ADVERSE EFFECTS

A. Hypersensitivity – most frequently occurring side effect (3 to 10%)

1. Less frequent with oral administration, somewhat higher when administered intravenously.

2. Reactions include pruritus, rash (maculopapular, erythematous, or morbilloform), urticaria, angioedema, hypotension, vasodilation, shock, and anaphylaxis.

a. Anaphylaxis is rare, occurring in 0.004-0.015% of patients.

b. Mediated by antibodies produced against penicillin degradation products that become haptens when bound to tissue proteins.

c. Penicillin skin testing – occasionally used to predict hypersensitivity reactions when a history of a hypersensitivity reaction is unclear.

d. Desensitization is possible (oral or parenteral) in some patients.

3. Cross-allergenicity is observed among natural and semisynthetic penicillins due to their common nucleus – patients allergic to one penicillin product should be considered allergic to other members of the penicillin family, and caution should be used with some other -lactams.

12 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

4. Other allergic reactions include drug fever, serum sickness, Stevens-Johnson syndrome, erythema multiforme, toxic epidermal necrolysis, and exfoliative dermatitis

B. Neurologic

1. Direct toxic effect observed primarily in patients who receive large intravenous doses of some penicillins in the presence of concomitant renal dysfunction.

2. Irritability, jerking, confusion, generalized seizures

C. Hematologic

1. β-lactam-specific cytotoxic IgG or IgM antibodies are developed that bind to circulating WBC or platelets; cause cell lysis when antigen (penicillin) encountered by activation of the complement system

2. Leukopenia, neutropenia or thrombocytopenia - especially in patients receiving long- term (> 2 weeks) therapy

D. Gastrointestinal

1. Transient increases in liver enzymes – especially oxacillin, nafcillin, and carbenicillin

2. Nausea, vomiting

3. Diarrhea – especially with amoxicillin-clavulanate

4. Pseudomembranous colitis (Clostridium difficile diarrhea).

E. Interstitial Nephritis

1. Immune-mediated damage to renal tubules (cell-mediated immunity or antigen- antibody reactions) where the penicillin acts as a hapten when bound to renal tubular cells - most commonly associated with methicillin, but can occur with nafcillin and other penicillins.

2. Initial manifestations may be fever, eosinophilia, pyuria, eosinophiluria, and an abrupt increase in serum creatinine.

3. May progress to renal failure

13 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

F. Other adverse effects include phlebitis (nafcillin); pain and induration with IM injection (benzathine penicillin, penicillin G, ampicillin); hypokalemia (carbenicillin and ticarcillin because they act as nonreabsorbable anions resulting in increased excretion of potassium); sodium overload and fluid retention (ticarcillin, piperacillin)

IX. DOSING

From: Basic and Clinical Pharmacology, 10th edition, 2007, page 732

14 Pharmacology & Therapeutics Adrenergic Agonists & Antagonists August 29, 30 and 31, 2012 K. Scrogin, Ph. D.

- ADRENERGIC AGONISTS & ANTAGONISTS

GENERAL COMMENTS

The next three lectures will focus on therapeutic agents that activate (sympathomimetics) and inhibit the sympathetic nervous system. These drugs act directly or indirectly on the receptors that mediate sympathetic function. These receptors are known collectively as "adrenergic" or"adreno" receptors. Emphasis will be placed on mechanisms and site of drug action, clinical utility, major side effects and important contraindications for use of these therapeutic agents. Subsequent lectures will focus on drugs that influence the parasympathetic side of the autonomic system. Therefore, the present lecture material will briefly cover some basic concepts in general autonomic function. Facts that are underlined should be the main focus of learning.

I. Anatomy

A. Autonomic Nervous System – is defined as an involuntary motor system. It is composed of sympathetic (thoracicolumbar division), parasympathetic (craniosacral) and enteric nervous systems. The sympathetic and parasympathetic systems are comprised of two sets of fibers arranged in series with the exception of the adrenal gland. Pre-ganglionic cells arise from the intermediolateral cell column of the spinal cord and project to clusters of cell bodies, or “ganglia” that give rise to post-ganglionic cells that innervate the effector organ. The adrenal gland acts like a ganglion but releases hormone into the circulation.

Overview of autonomic motor innervation to the organ systems Modified From: Katzung, Basic and ClinicalPharmacology, 9th Ed.McGraw-Hill, New York, 2004.

1. Sympathetic - thoracolumbar division (short pre-ganglionic cells and long-post ganglionic cells)

2. Parasympathetic - craniosacral division (long pre-ganglionic cells and short post-ganglionic cells)

1 Pharmacology & Therapeutics Adrenergic Agonists & Antagonists August 29, 30 and 31, 2012 K. Scrogin, Ph. D.

3. Enteric nervous system

The enteric nervous system (ENS) innervates the gastrointestinal tract, pancreas and gallbladder The ENS can function autonomously, but its activity is modified by both the sympathetic and parasympathetic autonomic nervous systems. Innervation from the sympathetic and parasympathetic systems provides

1) a second level of control over digestion 2) over-ride of the intrinsic enteric activity in times of emergency or stress (e.g., fight or flight).

From: Katzung, Basic and Clinical Pharmacology, 9th Ed.McGraw-Hill, New York, 2004.

II. Neurochemistry of the Autonomic Nervous system

A .Pre-ganglionic fibers release acetylcholine

B. Post-ganglionic parasympathetic fibers release acetylcholine

C. Post-ganglionic sympathetic fibers release norepinephrine (NE) (NE = noradrenaline; hence “adrenergic”)

D. Adrenal medulla releases epinephrine (EPI) and NE (to a lesser extent) into the circulation

E. Exceptions: Post-ganglionic sympathetic fibers that innervate sweat glands and some skeletal muscle blood vessels that release acetylcholine.

III. Functional Organization of the Autonomic System – Some organs receive dual innervation, while other systems do not.

A. Parasympathetic - “Rest and Digest”

Eye – innervation of circular (or sphincter) muscles of pupil - constriction (miosis)

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Heart – innervates sinoatrial node to reduce heart rate, and AV node to slow conduction.

Bronchioles – innervates smooth muscle of bronchi – causes constriction

GI tract – innervates all portions of the GI tract to promote secretions and motility

Bladder – innervates detrusor muscle, when activated causes bladder emptying

B. Sympathetic - “Fight or Flight”, major effects:

Eye – innervates radial (or dilator) muscle causes mydriasis, innervates ciliary body to stimulate production of aqueous humor

Katzung, Basic and ClinicalPharmacology, 9th Ed.McGraw-Hill, New York, 2004.

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Heart - accelerated sinoatrial node pacemaker depolarization (increased heart rate).

KES, 2012

Three currents contribute to sinoatrial node membrane potential,

1) inward calcium current 2) a hyperpolarization-induced inward current or "funny current" (mediated by hyperpolarization activated cyclic nucleotide gated channel, a non selective cation channel) 3) outward K+ current.

Sympathetic activation increases inward calcium current and the funny current to promote faster spontaneous depolarization during phase 4 of sinoatrial node action potential and lower threshold for activation. Sympathetic activation also stimulates greater calcium influx into myocytes during depolarization culminating in greater contractile force of the heart.

Bronchioles – relaxation of smooth muscle lining the bronchioles

Blood vessels - contraction and relaxation - dependent on receptor population expressed in targeted vascular bed (e.g., alpha1 vs. beta2), as well as the ligand mediating the vascular response.

GI tract - decreased motility, can override normal enteric nervous system during fight or flight.

Bladder - inhibits emptying by contracting urethral sphincters and relaxing body of bladder (detrusor muscle) during urine storage.

Metabolic functions - increases blood sugar (gluconeogenesis, glycogenolysis, lipolysis).

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IV. Adrenergic Function

A. Adrenergic Neurotransmission

1. synthesis- Tyrosine hydroxylase (the rate limiting step in DOPA formation. DOPA is metabolized to dopamine (DA). Half the DA produced is transported into storage vesicles via the vesicle monamine transporter (VMAT), the other half is metabolized.

2. Storage in vesicles – Synaptic vesicles contain ATP and dopamine -hydroxylase the latter of which converts dopamine to norepinephrine. Adrenal medullary cells from: B.G. Katzung, In: Basic and produce norepinephrine (NE), or epinephrine (EPI). EPI- Clinical Pharmacology, containing cells also synthesize an additional enzyme, Examination and Board Review, phenylethanolamine-N-methyltransferase, that converts NE to 6th Ed. McGraw-Hill, New York, 2002 EPI.

3. Release of catecholamines - Voltage dependent opening of calcium channels elevates intracellular calcium and stimulates the interaction of SNARE proteins to enable vesicle fusion with post-synaptic membrane and exocytosis of the vesicle contents.

4. Binding of neurotransmitter to post-synaptic or pre-synaptic sites- Neurotransmitters bind to receptors localized on pre-synaptic or post-synaptic cell membranes. The action of neurotransmitter binding depends upon the receptor type, the second messenger system as well as the machinery of the cell type.

5. Termination of action -three mechanisms account for termination of action in sympathetic neurons: 1) re-uptake into nerve terminals or post-synaptic cell, 2) diffusion out of synaptic cleft and 3) metabolic transformation. Inhibition of reuptake produces potent sympathomimetic effects indicating the importance of this process for normal termination of the neurotransmitter’s effects. Inhibitors of metabolism, i.e., inhibitors of monoamine oxidase (MAO) and catechol-o-methyltransferase (COMT) are very important in the metabolism of catecholamines within the nerve terminal and circulation respectively.

V. Adrenergic Receptors

Adrenergic receptors are coupled to G proteins that mediate receptor signaling by altering ion channel conductance, adenylyl cyclase activity and phospholipase C activation. Several adrenergic receptor subtypes are targeted in clinical pharmacology including 1-, 2-, 1- and 2- receptor subtypes. 3 receptors are involved in fat metabolism and will become an important therapeutic target in the future.

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A. Distribution of Adrenergic receptor subtypes

Modified from: B.G. Katzung, In: Basic and Clinical Pharmacology, Examination and Board Review, 6th Ed. McGraw-Hill, New York, 2002

B. Adrenergic Receptor Signaling

1. α1-adrenergic receptors are positively coupled to Phospholipase C (PLC) via Gq/11  protein of the heterotrimeric G protein family to increase IP3/DAG.

Ex: Vascular smooth muscle contraction. NE, EPI or other 1 -adrenergic receptor agonists bind to 1-adrenergic receptor of vascular smooth muscle, the Gq subunit activates PLC, which liberates inositol 1,4,5-trisphosphate (IP3) and diacylglycerol (DAG). IP3 activates IP3 Modified From: Katzung, Basic and ClinicalPharmacology, 9th Ed.McGraw-Hill, New receptor (ryanodine receptor) that also acts as a York, 2004. calcium channel in the sarcoplasmic reticulum. When activated the ryanodine receptor releases stored calcium into the intracellular space, thereby increasing calcium concentrations and stimulating smooth muscle contraction.

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2. α2-adrenergic receptors negatively couple to adenylyl cyclase via Gi subunit which inhibits cAMP formation.

Ex: Pre-synaptic 2 receptor activation decreases neurotransmitter release (reduced calcium influx). Agonist ligand binds to pre-synaptic 2 adrenergic receptor and inhibits adenylyl cyclase in the pre-

from: B.G. Katzung, In: Basic and Clinical Pharmacology, Examination and Board Review, 6th Ed. McGraw-Hill, New York, 2002

synaptic cell which reduces cAMP and inturn reduces activation of phosphokinase A (PKA). Consequently, phosphorylation of N-type calcium channels on nerve terminals is reduced, thereby reducing calcium influx during membrane depolarization and reducing Modified From: Katzung, Basic and Clinical Pharmacology, 9th Ed. McGraw-Hill, New York, 2004 vesicular release of neurotransmitter.

3. β1-adrenergic receptors positively couple to adenylyl cyclase via Gs-proteins – increases cAMP

Modified From: Katzung, Basic and ClinicalPharmacology, 9th Ed.McGraw-Hill, New York, 2004.

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EX: Positive chronotropy. Activation of adenylyl cylcase and increase of cAMP can activate PKA to promote phosphorylation of calcium channels in the membrane of sinoatrial node cells leading to increased inward calcium current and thus faster nodal cell depolarization to the firing threshold.

EX: Positive Inotropy: Increased cAMP leads to increased PKA-dependent phosphorylation of L-type calcium channels in myocyte membrane which leads to enhanced calcium influx and larger trigger signal for release of calcium from the sarcoplasmic reticulum into the intracellular space. Trigger calcium also enters the sarcoplasmic reticulum increasing calcium storage such that next trigger initiates larger efflux of calcium through ryanodine receptors.

from: B.G. Katzung, In: Basic and Clinical 4. β2-adrenergic receptors Pharmacology, Examination and Board Review, 6th positively couple to adenylyl cyclase via Ed. McGraw-Hill, New York, 2002 Gs protein - increases cAMP

EX: Vascular smooth muscle relaxation: cAMP activates PKA which phosphorylates and inactivates myosin light chain kinase (MLCK). Normally MLCK phosphorylates the light chain of myosin enabling actin and myosin cross-bridge formation and smooth muscle contraction. Remember though that phosphorylation of the MLCK enzyme inactivates the enzyme so it cannot phosphorylate myosin light chain. In this case PKA inactivates MLCK. Therefore, 2 adrenergic receptor activation leads to reduced smooth muscle contraction. 2 adrenergic receptors are highly expressed on smooth muscle of the bronchi and some vascular beds and therefore regulates the degree of airway constriction as well as peripheral vascular resistance.

From: Katzung, Basic and ClinicalPharmacology, 9th Ed.McGraw-Hill, New York, 2004.

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2-adrenergic receptors produce peripheral vasoconstriction through the opposite mechanism. In this case, the Gi subunit, to which the 2 adrenergic receptor is coupled, inhibits adenylyl cyclase, which, in turn, inhibits cAMP and PKA. PKA normally phosphorylates and inhibits the activity of myosin light chain kinase. Therefore, inihibiton of PKA leads to activation of MLCK and vascular smooth muscle constriction.

Modified From: Katzung, Basic and ClinicalPharmacology, 9th Ed.McGraw-Hill, New York, 2004.

VI. Adrenergic Agonists

from: B.G. Katzung, In: Basic and Clinical Pharmacology, Examination and Board Review, 6th Ed. McGraw-Hill, New York, 2002

A. Direct Acting Sympathomimetics: Direct acting sympathomimetics (i.e., drugs that stimulate the sympathetic system) interact directly with adrenergic receptors to mediate their effects. Sympathomimetic agents have different affinities for adrenergic receptor subtypes. Thus, a specific compound may be more or less potent in producing a specific effect depending upon the affinity of the compound for a specific receptor subtype. The endogenous ligands for adrenergic receptors are NE, EPI and dopamine (DA).

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Catecholamines contain two hydroxyl groups on a phenyl ring. This structure makes catecholamines susceptible to degradation by metabolic enzymes. Catecholamines differ in the substitutions present on the terminal amine and the two methyl groups. Adrenergic agonists can be made more or less selective for various adrenergic receptors by altering the substitutions on the methyl and amine groups. For instance, isoproterenol (ISO), a synthetic catecholamine, has a particularly large substitution on the amine group. This gives the compound selectivity for the - adrenergic receptors. Compounds may also be more or less susceptible to degradation or be more or less lipophylic by altering the hydroxyl groups on the pheyl ring.

It is important to recognize the difference in efficacy of the various catecholamines at different receptors in order to correctly anticipate their physiological effects.

α1-adrenergic: epinephrine > norepinephrine >> isoproterenol

α2 adrenergic: epinephrine > norepinephrine >> isoproterenol

β2-adrenergic: Isoproterenol > epinephrine >> norepinephrine

β1-adrenergic: Isoproterenol > epinephrine = norepinephrine

It is important to be able to predict the different hemodynamic effects produced by sympathomimetic agents given their receptor activity in order to effectively predict whether they will be beneficial or potentially hazardous in a particular clinical situation.

MAP = CO x TPR, where MAP is mean arterial pressure, CO is cardiac output and TPR is total peripheral resistance.

TPR has a predominant effect on diastolic pressure (prevailing arterial pressure after the systolic wave has passed is mediated by arterial vasoconstriction) CO has a predominant effect on systolic pressure (acute increase during systole due to contractile force of the heart and blood volume passing through the arterial tree) Therefore TPR and diastolic pressure are affected more by adrenergic receptors expressed in vasculature while CO and systolic pressure are affected more by adrenergic receptors in cardiac tissue.

1. Epinephrine: Stimulates α1, 2, 1 and β2 receptors (receptor effects predominate at low concentrations), short acting, due to susceptibility to degradation.

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Cardiovascular effects: at low infusion rates (<0.01 g/kg/min, dashed lines in figure at right), β2 receptor activation causes peripheral vasodilation therefore decreases diastolic BP; β1 receptor activation has positive inotropic and chronotropic effects therefore increases CO and systolic BP; at higher doses (>0.2 g/kg/min, solid lines) α1 receptor activation predominates producing peripheral vasoconstriction, elevated systolic pressure and elevated diastolic pressure. Overall, the cardiovascular effect is a slight increase in mean BP at lower doses, with quite robust increases at higher concentrations.

Bronchiole effect: β2 receptor - bronchodilation, α1 from: B.G. Katzung, In: Basic and receptor - decrease in bronchial secretions Clinical Pharmacology, Examination and Board Review, 6th Toxicity: Arrhythmias, cerebral hemorrhage, anxiety, Ed. McGraw-Hill, New York, 2002 cold extremities, pulmonary edema

Therapeutic Uses: Anaphylaxis, cardiac arrest, bronchospasm

Contraindications: late term pregnancy due to unpredictable effects on fetal blood flow

2. Norepinephrine: has high affinity and efficacy at  and 1 receptors with little affinity for 2 receptors, susceptible to degradation by metabolic enzymes, short half- life give by controlled infusion.

Cardiovascular effects: due primarily to α1- receptor activation which leads to vasoconstriction - increase in TPR, and diastolic BP; also produces significant positive inotropic and chronotropic effects on heart and increased systolic BP due to 1 receptor binding; large rise in pressure leads to reflex baroreceptor response and decrease in HR which predominates over the direct chronotropic effects; Overall increase in MAP; NE has limited affinity for 2 receptors and so has limited effects on bronchiole smooth from: B.G. Katzung, In: Basic and Clinical muscle. Pharmacology, Examination and Board Review, 6th Ed. McGraw-Hill, New York, 2002 Toxicity: Arrhythmias, ischemia, hypertension

Therapeutic Use: Limited to vasodilatory shock

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Contraindications: pre-existing excessive vasoconstriction and ischemia and late term pregnancy

3. Dopamine: stimulates D1 receptors at low concentrations, but also has affinity for 1 and  receptors which may be activated at higher infusion rates, metabolized readily.

Cardiovascular Effects: activates D1-receptors at low infusion rates (0.5-1.0 g/kg/min) leading to decreased TPR, at medium infusion rates activates 1-receptors leading to increased cardiac contractility andincreased HR; at still higher infusion rates (>10g/kg/min) it stimulates - receptors leading to increased BP and TPR.

Toxicity: low infusion rates – hypotension, high infusion rates – ischemia

Therapeutic Use: Hypotension due to low cardiac output during cardiogenic shock- may be advantageous due to vasodilatory effect in renal and mesenteric vascular beds

Contraindications: uncorrected tachyarrhythmias or ventricular fibrillation

VI. Direct acting sympathomimetics (synthetic compounds)

A. Non-selective β-adrenergic agonists: isoproterenol: potent β-receptor agonist with no appreciable affinity for α receptors. Catecholamine structure means it is susceptible to degradation.

Cardiovascular effects: β2 receptor activation promotes peripheral vasdilation, decreased diastolic BP; β1 receptor - positive inotropy and chronotropy, leads to transient increased systolic BP. Overcome by vasodilatory effect; Overall small decrease in MAP which may contribute to further reflex HR increase.

Bronchioles: β2 receptor – bronchodilation

Toxicity: Tachyarrhythmias from: B.G. Katzung, In: Basic and Clinical Pharmacology, Examination and Board Therapeutic uses: Cardiac stimulation during Review, 6th Ed. McGraw-Hill, New York, bradycardia or heart block when peripheral resistance is high.

Contraindications: Angina, particularly with arrhythmias

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B. Selecitve 1-adrenergic receptor agonist - Dobutamine (adrenergic receptor affinity: 1>2>), though considered by most to be a 1 selective agonist. Dobutamine is a catecholamine that is rapidly degraded by COMT.

Cardiovascular effects: increased CO, usually little effect on peripheral vasculature or lung; unique in that positive inotropic effect > positive chronotropic effect due to lack of 2-mediated vasodilation and reflex tachycardia. However, no agonist is purely selective so at higher doses, 2 agonist activity may cause hypotension with reflex tachycardia.

Toxicity: Arrhythmias, hypotension (vasodilation), hypertension (inotropic and chronotropic effects).

Therapeutic Use: Short-term treatment of cardiac insufficiency in CHF, cardiogenic shock or excess -blockade

C. Selective 2 adrenregic agonists: terbutaline, albuterol

Cardiovascular Effects: negligible in most patients due to lack of 1 activity. However, can cause some 1 agonist-like response

Bronchioles: Bronchodilation

Pregnant Uterus: Relaxation

Toxicity: Tachycardia, tolerance, skeletal muscle tremor (see figure right), activation of 2-receptors expressed on pre- synaptic nerve terminals of cholinergic somatomotor neurons increases release of neurotransmitter. This can lead to muscle tremor, a side effect of -agonist therapy.

Therapeutic Use: Bronchospasm, chronic treatment of obstructive airway disease.

D. Selective 1-adrenergic agonist: phenylephrine

Cardiovascular Effects: Peripheral vasoconstrictionand KES, 2007 increased BP, activates baroreceptor reflex and thereby decreases HR.

Ophthalmic Effects: Dilates pupil

Bronchioles: Decrease bronchial (and upper airway) secretions

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Toxicity: Hypertension

Therapeutic Use: Hypotension during anesthesia or shock, paroxysmal supraventricular tachycardia, mydriatic agent, nasal decongestant

NOTE: Phenylephrine is not a catecholamine and therefore is not subject to rapid degradation by COMT. It is metabolized more slowly; therefore it has a much longer duration of action than endogenous catecholamines.

Contraindications: Hypertension

E. Selective α2-adrenergic agonists: clonidine

Cardiovascular Effects: Peripherally, clonidine causes mild vasoconstriction and slight increase in BP, also crosses BBB to cause reduced sympathetic outflow thereby reducing vasoconstriction and BP (see figure at right). The loss of sympathetic activity predominates over the direct vasoconstrictor effects of the drug leading to overall reduction in blood pressure.

Activation of 2-receptors on pre-motor neurons that normally provide tonic activation of sympathetic pre-ganglionic cells reduces pre-motor neural activity by unknown mechanism. Reduction of tonic excitatory input to the sympathetic cells reduces sympathetic output to vascular smooth muscle.

Toxicity: Dry mouth, sedation, bradycardia, withdrawal after chronic use can result in life- threatening hypertensive crisis (increases sympathetic activity).

Therapeutic Use: Hypertension when cause is due to excess sympathetic drive

VII. Indirectly acting sympathomimetics: Indirect acting sympathomimetic agents increase the concentration of endogenous catecholamines in the synapse and circulation leading to activation of adrenergic receptors. This occurs via either: 1) release of cytoplasmic catecholamines or 2) blockade of re-uptake transporters

A. Releasing agents: amphetamine, methamphetamine, methylphenidate, ephedrine, pseudoephedrine, tyramine. Most are resistant to degradation by COMT and MAO

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and therefore have relatively long half- lives (exception is tyramine which is highly susceptible to degradation by MAO and thus has little effect unless patient is taking MAO inhibitor). Amphetamine-like drugs are taken up by re-uptake proteins and subsequently cause reversal of the re-uptake mechanism resulting in release of neurotransmitter in a calcium-independent manner. The resulting increase in synaptic NE mediates the drugs' effects. Amphetamine-like drugs readily cross the blood brain barrier leading to high abuse potential due to reinforcing effects of central dopamine release.

Cardiovascular Effects: due to NE release, α adrenergic receptor activation causes peripheral vasoconstriction and increased diastolic BP; β receptor activation of heart leads to positive inotropy and increased conduction velocity and increased systolic BP; increased BP can cause decreased HR due to baroreceptor activation, but this can be masked by direct chronotropic effect.

Central Nervous System: Stimulant, anorexic agent

Toxicity: Anxiety, tachycardia

Therapeutic use: Attention Deficit Disorder, narcolepsy, nasal congestion

Contraindications: Hypertension, severe athrosclerosis, history of drug abuse, Rx with MAO inhibitors within previous 2 weeks

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VIII. β-adrenergic receptor antagonists

A. Mechanism of action of the 3 main categories of -blockers, i.e., non-selective, cardioselective and partial agonists. FYI: the term "blocker" is equivalent to "antagonist".

Cardioselective Non-Selective (β1 and β2) Partial Agonist (β1 and β2) (β1) PROPRANOLOL, ATENOLOL, PINDOLOL TIMOLOL, NADOLOL METOPROLOL

Heart Rate and Decreases both rate and force Decrease both Force of Decrease both rate and of contraction. However, rate and force of Contraction (β ) force of contraction bradycardic response is limited 1 contraction due to partial agonist activity.

Peripheral Little effect Increase, due to unopposed Resistance (β ) because β - May be slight decrease because 2 vasoconstriction by α - 2 1 receptors are not of partial β agonist properties receptors 2 blocked

Renin Release Decreased release Decreased release Decreased release (β1)

Bronchioles (β2) Less bronchoconstricti Bronchoconstriction, on in asthmatics, Asthmatics have a reduced particularly in asthmatics but still not capacity to dilate bronchioles. recommended in these patients

Glucose Inhibits effects of Metabolism (β ) epinephrine, e.g., 2 Reduced response to hyperglycemia, anxiety, epinephrine because partial sweating. Use caution in Little effect agonist activity is not as potent diabetics using insulin, as endogenously-released since masks symptoms of epinephrine hypoglycemia (normally due to epinephrine release)

B. Non-selective -blockers: propranolol, nadolol, timolol, first generation -blockers with potentially harmful side effects for patients with respiratory disease.

Cardiovascular effects: Reduced heart rate and contractility, reduced renin release leads to reduced angiotensin II release and thus reduced vasoconstriction, probably reduced sympathetic activation due to central effects in lipid soluble drugs. Possible peripheral vasoconstriction due to blockade of 2 receptors.

Bronchioles: can cause bronchiole constriction in those with asthma or chronic obstructive pulmonary disease.

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Therapeutic Use: Hypertension, angina, glaucoma, heart failure, arrhythmia, thyrotoxicosis, anxiety

Toxicity: Bronchospasm, masks symptoms of hypoglycemia, CNS effects including insomnia and depression (most significant with lipid soluble drugs), some can raise triglycerides, bradycardia.

Contraindications: Bronchial Asthma, sinus bradycardia, 2nd and 3rd degree heart block, cardiogenic shock

C. Cardioselective 1-blockers: metoprolol, atenolol, esmolol, second generation - blockers developed for their ability to reduce respiratory side effects.

Cardiovascular Effects: Same as for non-selective -blockers with limited effects on peripheral resistance.

Therapeutic Use: Hypertension (metoprolol, atenolol), angina (metoprolol, atenolol), arrhythmia (esmolol-emergent control). Esmolol has very short half-life (~9 min) so is given i.v. in hypertenisve crisis, unstable angina or arrhythmias when longer acting beta blockers may be problematic.

Toxicity: (typically mild and transient), Dizziness, depression, insomnia, hypotension, bradycardia.

Contraindications: Sinus bradycardia, 2nd or 3rd degree heart block, cardiogenic shock severe heart failure

D. Partial Agonist: pindolol, partial agonist activity at both 1 and 2 adrenergic receptors; Therapeutic benefit is good when hypertension is due to high sympathetic output (A below) since blockade of endogenous agonist (i.e., NE and EPI) will predominate over partial agonist effect (B below) of drug. Partial agonists have less bradycardic effect since some signal remains, while signal is blocked by agonists without agonist activity (C below). Used when patients are less tolerant of bradycardic effects.

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Cardiovascular Effects: Same as above for non-selective -blockers, particularly when sympathetic activity is high.

Therapeutic Use: Hypertension in those who are less tolerant of bradycardia and reduced exercise capacity caused by other beta blockers without partial agonist activity

Toxicity: same as for non-selective

Contraindications: Same as above

IX. -adrnergic receptor antagonists

A. Non-selelctive α-receptor antagonists: phenoxybenazmine (irreversible) and phentolamine (reversible).

Effects of reversible and irreversible non-selective -adrenergic receptor antagonists on dose-response curves to Norepinephrine Figure 10-2 from Katzung.

Cardiovascular Effects: Inhibit vasoconstriction therefore decreases BP, increased inotropy and chronotropy due to blockade of pre-synaptic α2-receptor and increased release of NE from nerve terminals, reflex increase in NE release also occurs in response to hypotension, unmasks vasodilatory effect of EPI (which has both α and β2 effects.)

Therapeutic Use: Hypertension associated with perioperative treatment of pheochromocytoma, test for pheochromocytoma, dermal necrosis and sloughing with vasoconstrictor extravasation

Toxicity: Prolonged hypotension, reflex tachycardia, nasal congestion

Contraindications: Coronary artery disease

B. Selective α1-receptor blockers: prazosin, doxazosin, and terazosin:

Cardiovascular Effects: Inhibit vasoconstriction, resulting in vasodilation and decreased BP, produces less cardiac stimulation than non-selective -blockers due to preservation of 2- adrenergic function (see figure below).

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Modified from T.M. Brody, J. Lamer, K.P. Minnemon, IN: Human Pharmacology, Molecular to Clinic, Mosby 1998

Therapeutic Use: Hypertension, benign prostatic hyperplasia

Toxicity: Syncopy, orthostatic hypotension

19 Pharmacology & Therapeutics Adrenergic Agonists & Antagonists August 29, 30 and 31, 2012 K. Scrogin, Ph. D.

X. Drugs Covered in Lecture (Bold text is information you should know) Do not memorize bold half-lives but have a general idea of the drug's half-life relative to other drugs in its class, e.g. Nadolol vs propranolol. Trade Mechanism of Generic Name Half-Life Elimination Rx Name action

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Anaphylaxis, Adrenaline shock, cardiac Epinephrine short α and β agonist COMT-urine Chloride arrest and heart block α-agonist, 1- MOA and COMT Acute hypotension Norepinephrine Levophed short agonist -urine due to shock -agonist, some Dopamine Dopamine ~2min MOA and COMT Cardiogenic shock -agonist activity Transient heart block, broncho- Isoproterenol Isuprel short β-agonist COMT-urine spasm during anesthesia Short term Rx for Dobutamine Dobutrex 2-3 min 1-agonist COMT-urine low cardiac contractility Prevent and reverse Terbutaline Brethine 2.9 β2-agonist Urine bronchospasm in asthma, bronchitis and emphysema

Bronchial SM Albuterol Ventolin 5 hr β2-agonist Urine relaxation

Pressor agent for anesthesia, nasal Neo- Phenylephrine < 1 hr 1-agonist MAO congestion, dilate synephrine pupil for eye exam, supraventricular

Hypertension, Clonidine Catapres 12-16 hrs α2-agonist Urine analgesia

Indirect Amphetamine Adderall 10-13 hr Urine ADHD sympathomimetic

Indirect Methylphenidate Ritalin 2-3 hr Urine ADHD sympathomimetic

Indirect Pressor agent with Ephedrine Ephedrine 3-6 hr Urine sympathomimetic anesth. Indirect Methylphenidate Ritalin 2-3 hr Urine ADHD sympathomimetic Pseudo- Indirect Sudafed 4.3-8 hr Liver Nasal decongestion ephedrine sympathomimetic

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Normally Tyramine tyramine very Displaces NE MAO Not therapeutic short Hypertension, Propranolol Inderal 4 hr β-blocker Liver angina due to atherosclerosis, MI Blocaden Timolol 4 hr β-blocker Liver Glaucoma. (po)

Long-term angina, Nadolol Corgard 20-24 hr β-blocker Urine hypertension

Hypertension, Atenolol Tenormin 6-7 hr β1-blocker Urine angina, MI

Hypertension, Lopressor, Metoprolol 3-7 hr β1-antagonist Liver long-term angina Toprol rx β-antagonist Pindolol Visken 3-4 hr (with partial Urine Hypertension agonist activity)

Supraventricular Esmolol Breviblock ~9 min 1-blocker Esterases in RBC tachycardia

Phenoxy- Conjugates to Pheochromo- Dibenzyline 24 hr (iv) α-blocker benzamine receptor cytoma Test for pheochromo- cytoma, rx for Phentolamine Regitine 19 min α-blocker Urine pheo. before surg., Catecholamine extravasation

Prazosin Minipress 2.3 hr α-blocker Liver Hypertension

Prostatic Doxazosin Cardura 22 hr α1-antagonist Liver hyperplasia, hypertension Prostatic Terazosin Hytrin 12 hr α1-blocker Urine and fecal hyperplasia, hypertension

22 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

CEPHALOSPORINS Original Handout written by S. Erdman, Pharm.D. presented by J. Lentino, M.D.

I. INTRODUCTION

Cephalosporins are semisynthetic -lactam antibiotics that are structurally and pharmacologically related to the penicillins. The first source of cephalosporins, a fungus named Cephalosporium acremonium, was isolated in 1948. The crude filtrates from this fungus were found to inhibit the in vitro growth of Staphylococcus aureus, as well as treat staphylococcal infections and typhoid fever in humans.

II. CHEMISTRY

A. Cephalosporins contain a -lactam ring where the 5-membered thiazolidine ring of the penicillins is replaced by a 6-membered dihydrothiazine ring. This structural difference provides stability against many -lactamase enzymes that render the penicillins inactive.

B. Structural modifications at position 7 of the -lactam ring are associated with changes in antibacterial activity, while changes at position 3 of the dihydrothiazine ring are associated with changes in the pharmacokinetic properties of the cephalosporins.

C. Cephamycins are cephalosporins with a methoxy group at position 7 of the -lactam ring (confers activity against anaerobes such as Bacteroides spp.).

A = dihydrothiazine ring, B = β-lactam ring, R = acyl side chain

III. MECHANISM OF ACTION

A. Cephalosporins, like penicillins, interfere with cell wall synthesis by binding to and inhibiting enzymes called penicillin-binding proteins (PBPs) that are located in the cell wall of bacteria.

1 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

B. PBPs include transpeptidases, carboxypeptidases, and endopeptidases that are responsible for peptidoglycan cross-linking. The number, type and location of PBPs vary between bacteria.

C. Inhibition of PBPs by -lactam antibiotics leads to inhibition of the final transpeptidation step of peptidoglycan synthesis, exposing a less osmotically stable cell wall that leads to decreased bacterial growth, bacterial cell lysis, and death.

D. Cephalosporins, like all -lactam antibiotics, are bactericidal.

IV. MECHANISMS OF RESISTANCE

A. There are 3 primary mechanisms of resistance to cephalosporins

1. Production of -lactamase enzymes

a. The most important and most common mechanism of bacterial resistance where the bacteria produces a -lactamase enzyme that hydrolyzes the cyclic amide bond of the -lactam ring, inactivating the antibiotic.

b. Over 100 different -lactamase enzymes have been identified. - lactamase enzymes may be plasmid-mediated or chromosomally- mediated, constitutive or inducible.

c. Produced by many gram-negative (H. influenzae, N. gonorrhoeae, M. catarrhalis, K. pneumoniae, E. coli, Proteus spp., P. aeruginosa, S. marcescens, etc.), some gram-positive (Staphylococcus aureus), and some anaerobic (Bacteroides fragilis) bacteria.

d. Cephalosporins have variable susceptibility to -lactamases; 3rd and 4th generation cephalosporins are the most resistant to hydrolysis by - lactamase enzymes produced by gram-negative aerobic bacteria.

e. Some bacteria (SPICE) have the ability to produce -lactamase enzymes when exposed to antibiotics that induce their production – these are called inducible -lactamases (such as during treatment of Enterobacter spp. infections with ceftazidime).

2. Alterations in PBPs that lead to decreased binding affinity of cephalosporins to PBPs (e.g., methicillin-resistant S. aureus, penicillin-resistant S. pneumoniae).

3. Inability of the antibiotic to reach the PBP target due to poor penetration through the outer membrane (gram-negative bacteria).

2 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

V. CLASSIFICATION AND SPECTRUM OF ACTIVITY

A. Currently-available cephalosporins are divided into 4 major groups, called “generations”, based primarily on their antimicrobial activity and stability against - lactamase enzymes.

B. In general, 1st generation cephalosporins are best for gram-positive aerobes with activity against a limited number of gram-negative aerobes. As you move down the generations to 2nd and 3rd, gram-positive activity decreases with an increase in activity against gram-negative aerobes. Fourth generation cephalosporins are active against gram-positive and gram-negative aerobes. Also see greater stability against -lactamase enzymes as you move through the generations.

1. First Generation Cephalosporins

a. Excellent activity against gram-positive aerobes - the best activity of all cephalosporins

Methicillin-susceptible Staphylococcus aureus (MSSA) Penicillin-susceptible Streptococcus pneumoniae Group A (S. pyogenes) and Group B streptococci (S. agalactiae) Viridans streptococci

b. Also have activity against a limited number of gram-negative aerobes (PEK):

Proteus mirabilis Escherichia coli Klebsiella pneumoniae

c. Examples of 1st generation cephalosporins (*most often used)

Generic Name Brand Name Route of Administration cefazolin* Ancef, Kefzol intravenous cephalothin Keflin, Seffin intravenous cephradine Velosef, Anspor intravenous, oral cephapirin Cefadyl intravenous cephalexin* Keflex, Keftab, Biocef oral cefadroxil Duricef, Ultracef oral

2. Second Generation Cephalosporins (includes cephamycins and carbacephems)

a. Differences exist in the spectrum of activity among 2nd generation agents because of their structural variability.

3 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

b. In general, are slightly less active than 1st generation agents against gram- positive aerobes such as staphylococci and streptococci (MICs are higher), but are more active against gram-negative aerobes, and for some 2nd generation agents (cephamycins), anaerobes.

c. Gram-positive aerobes - 2nd generation agents have activity against the same bacteria as 1st generation agents, with MICs similar to or slightly higher than 1st generation agents. Cefprozil and cefuroxime have the best gram-positive coverage; cefoxitin and cefotetan have the worst.

d. Gram-negative aerobes - display activity against P. mirabilis, E. coli, and K. pneumoniae like the 1st generation cephalosporins, but they have expanded coverage including:

Haemophilus influenzae Moraxella catarrhalis Neisseria spp.

In addition, may be active against some strains of Citrobacter and Enterobacter that are resistant to 1st generation agents (HENPEK).

e. Anaerobes - only cefoxitin, cefotetan and cefmetazole (the cephamycins) are active against anaerobes including Bacteroides fragilis (cefoxitin is the best).

f. Examples of 2nd generation cephalosporins (* most common)

Generic Name Brand Name Route of Administration cefuroxime* Kefurox, Zenacef intravenous and oral cefamandole Mandol intravenous cefonicid Monocid intravenous cefaclor Ceclor oral cefprozil* Cefzil oral Carbacephems loracarbef Lorabid  oral Cephamycins cefoxitin* Mefoxin intravenous cefotetan Cefotan intravenous cefmetazole Zefazone intravenous

3. Third Generation Cephalosporins

a. In general, are less active than 1st or 2nd generation agents against gram-positive aerobes, but have enhanced activity against gram- negative aerobes.

4 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

b. Gram-positive aerobes - ceftriaxone and cefotaxime have the best activity (among the only cephalosporins that have activity against penicillin-resistant S. pneumoniae), which is thought to be less than 1st or 2nd generation agents; other 3rd generation cephalosporins have relatively poor activity. c. Gram-negative aerobes - expanded spectrum of activity than the 2nd generation agents (HENPECKSSS and more) including:

P. mirabilis, E. coli, K. pneumoniae (better than 1st and 2nd generation agents) H. influenzae, M. catarrhalis, Neisseria gonorrhoeae (even - lactamase producing strains) Neisseria meningitidis Citrobacter spp., Enterobacter spp. (less with oral agents) Morganella spp., Providencia spp., Serratia marcescens Salmonella spp., Shigella spp. Pseudomonas aeruginosa - only ceftazidime and cefoperazone

d. Anaerobes - very limited activity (ceftizoxime has marginal activity)

e. Select 3rd generation cephalosporins (especially ceftazidime) are strong inducers of extended spectrum -lactamases (type 1 or Class C) in gram-negative aerobic bacteria (Enterobacter spp)

f. Examples of 3rd generation cephalosporins (* most commonly used)

Generic Name Brand Name Route of Administration cefotaxime Claforan intravenous ceftriaxone* Rocephin intravenous ceftazidime* Fortaz, Tazidime, Tazicef intravenous cefoperazone Cefobid intravenous ceftizoxime Cefizox intravenous moxalactam no longer commercially available cefixime Suprax oral cefpodoxime* Vantin oral ceftibuten Cedax oral cefdinir Omnicef oral

4. Fourth generation cephalosporins

a. Considered a 4th generation cephalosporin for 2 reasons

i. Extended spectrum of activity, including many gram-positive and gram-negative aerobes (NOT anaerobes)

5 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

Gram-positive aerobes: coverage against staphylococci and streptococci similar to ceftriaxone and cefotaxime

Gram-negative aerobes: displays similar coverage against gram- negative aerobes as 3rd generation agents, including:

Pseudomonas aeruginosa -lactamase producing Enterobacter and E. coli

ii. Excellent stability against -lactamase hydrolysis; is a relatively poor inducer of extended spectrum -lactamases (type 1 or Class C) in gram-negative aerobic bacteria.

b. 4th generation cephalosporin example

Generic Name Brand Name Route of Administration cefepime* Maxipime intravenous

C. Overall, cephalosporins are not active against methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci, Enterococcus spp., Listeria monocytogenes, Legionella pneumophila, Clostridium difficile, Stenotrophomonas maltophilia, and Campylobacter jejuni.

VI. PHARMACOLOGY (see Table on page 9)

A. General pharmacologic properties of cephalosporins

1. Orally-available cephalosporins are well absorbed from the gastrointestinal tract; however, serum concentrations are lower than those achieved with parenteral dosing. The influence of food on the absorption of individual agents is listed in the pharmacokinetic table.

2. Most cephalosporins are widely distributed into tissues and fluids including pleural fluid, synovial fluid, bone, bile, placenta, pericardial fluid and aqueous humor. Adequate concentrations in the cerebrospinal fluid (CSF) are NOT obtained with 1st and most 2nd generation cephalosporins. Therapeutic concentrations of parenteral cefuroxime, parenteral 3rd, and 4th generation cephalosporins are attained in the CSF, especially in the presence of inflamed meninges.

3. Most cephalosporins are eliminated unchanged by the kidneys via glomerular filtration and tubular secretion, and require dosage adjustment in the presence of renal insufficiency. The exceptions include ceftriaxone and cefoperazone, which are eliminated by the biliary system and the liver, respectively. Most

6 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

cephalosporins are removed during hemodialysis and require supplemental dosing after a hemodialysis procedure, with the exception of ceftriaxone.

4. Most cephalosporins have relatively short elimination half-lives (< 2 hours), and require repeated daily dosing (3 to 4 times daily) to maintain therapeutic serum concentrations. Exceptions include ceftriaxone (8 hours), cefonicid (4.5 hours), cefotetan (3.5 hours), and cefixime (3.7 hours).

B. Dosing guidelines for the cephalosporins in the presence of normal renal and hepatic function

Antibiotic and Route of Administration Adult Dosage Pediatric Dosage 1st generation cefazolin (IV) 1 - 2 grams every 8 hours 25 - 100 mg/kg/day in 3 to 4 divided doses cephalothin (IV) 1 - 2 grams every 4 hours 60 - 100 mg/kg/day in 4 to 6 divided doses cephalexin (PO) 250 - 500 mg every 6 hours 25 - 50 mg/kg/day in 4 divided doses cefadroxil (PO) 500 - 1,000 mg twice daily 30 mg/kg/day in 2 divided doses

2nd generation cefuroxime (IV) 0.75 - 1.5 g every 8 hours 75 - 100 mg/kg/day in 3 divided doses given every 8 hours cefoxitin (IV) 2 g every 6 hours 80 - 160 mg/kg/day in 4 to 6 divided doses cefotetan (IV) 1 to 2 grams every 12 hours 40 - 60 mg/kg/day in 2 divided doses cefuroxime (PO) 250 - 500 mg twice daily 125 - 250 mg twice daily cefprozil (PO) 250 - 500 mg twice daily 15 mg/kg twice daily

3rd generation cefotaxime (IV) 1 - 2 g every 6 to 8 hours 50 - 180 mg/kg/day in 4 divided doses ceftriaxone (IV) 1 - 2 g every 12-24 hours 50 - 100 mg/kg/day divided every 12 hours (max 4 g/day) ceftazidime (IV) 1 - 2 g every 8 hours 90 - 150 mg/kg/day in 3 divided doses cefixime (PO) 400 mg once daily 8 mg/kg/day once daily cefpodoxime (PO) 100 - 400 mg every 12 hours 10 mg/kg/day divided every 12 hours ceftibuten (PO) 400 mg once daily 9 mg/kg once daily cefdinir (PO) 300mg twice daily 7 mg/kg twice daily

4th generation cefepime (IV) 0.5 - 2 g every 8 to 12 hours up to 50 mg/kg every 8 hours has been used, not approved

7 Cephalosporins Joseph R.Lentino,M.D. ,Ph.D.

CEPHALOSPORIN PHARMACOKINETIC TABLE

PEAK SERUM ROUTE OF EFFECT OF FOOD SERUM GENERIC NAME CONC (g/ml) CSF CONC (g/ml) ELIMINATION HALF-LIFE hrs ON PEAK CONC PROT BIND %

1st generation

Cefazolin - IV 80 (1 g) Renal 1.8 80 Cephalothin - IV 30 (1 g) Renal 0.6 71 Cephalexin - PO 18 (0.5 g) Renal 0.9 None 10 Cefadroxil - PO 16 (0.5 g) Renal 1.2 None 20 Cephradine - PO 10 (0.5 g) Renal 0.7 None 10

2nd generation

Cefamandole - IV 150 (2 g) Renal 0.8 75 Cefonicid - IV 260 (2 g) Renal 4.5 98 Cefuroxime - IV 100 (1.5 g) 1.1 - 17 Renal 1.3 35 Cefoxitin - IV 150 (2 g) Renal 0.8 70 Cefotetan - IV 230 (2 g) Renal 3.5 90 cefuroxime axetil - PO 8 - 9 (0.5 g) Renal 1.3 Increased 35 Cefaclor - PO 13 (0.5 g) Renal 0.8 Decreased 25 Cefprozil - PO 10 (0.5 g) Renal 1.2 None 42 Loracarbef - PO 15 (0.4 g) Renal 1.1 Decreased 35

3rd generation

Cefotaxime - IV 130 (2 g) 5.6 - 44 Renal 1.0 35 Ceftriaxone - IV 250 (2 g) 1.2 - 39 Biliary/renal 8.0 83 - 96 Ceftizoxime - IV 130 (2 g) 0.5 - 29 Renal 1.7 30 Cefoperazone - IV 250 (2 g) Hepatic 2.0 87 - 93 Ceftazidime - IV 160 (2 g) 0.5 - 30 Renal 1.8 17 Cefixime - PO 3.9 (0.4 g) Renal 3.7 None 67 Cefpodoxime axetil - PO 4 (0.4 g) Renal 2.2 Increased 40 Ceftibuten - PO 11 (0.2 g) Renal 2.5 None 63 Cefdinir - PO 2.87 (0.6 g) Renal 1.8 None 60 - 70

4th generation

Cefepime - IV 150 (2 g) yes, unknown Renal 2.1 20 cefpirome 100 (1 g) 1.3 - 7.5 Renal 2.0 10

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

VII. CLINICAL USES

A. First generation cephalosporins

1. Orally-administered 1st generation cephalosporins achieve lower serum concentrations than parenteral agents and should only be used for the treatment of mild to moderate skin infections or uncomplicated urinary tract infections.

2. Treatment of skin and soft tissue infections, septic arthritis, osteomyelitis, and endocarditis due to MSSA and streptococci.

3. Cefazolin is the drug of choice for surgical prophylaxis against surgical site infections for many surgical procedures because of its activity against staphylococci; can usually be administered as a single preoperative dose.

4. First generation cephalosporins have coverage against a few gram-negative aerobes and can be used for the treatment of urinary tract infections (oral or intravenous) or bacteremias (intravenous) due to susceptible organisms (PEK).

5. First generation cephalosporins do not penetrate the central nervous system, and should NOT be used for meningitis.

B. Second generation cephalosporins

1. Due to their activity against gram-positives and expanded spectrum of activity against gram-negative bacteria including H. influenzae and M. catarrhalis, oral 2nd generation agents, such as cefuroxime, are useful for the treatment of pharyngitis, tonsillitis, sinusitis, otitis media, bronchitis and mild to moderate community-acquired pneumonia.

2. Oral 2nd generation cephalosporins are also useful for the treatment of mild to moderate skin and soft tissue infections, and uncomplicated urinary tract infections due to susceptible bacteria.

3. Although cefuroxime does penetrate the central nervous system, adequate CSF bactericidal activity is not routinely achieved so that it is no longer recommended for the treatment of meningitis.

4. The cephamycins, cefoxitin, cefotetan, and cefmetazole, have activity against gram-negative aerobes and anaerobes, including Bacteroides fragilis, so they are useful for prophylaxis in abdominal surgical procedures and for the treatment of polymicrobial infections such as intraabdominal infections (diverticulitis, appendicitis, bowel perforation), pelvic infections (pelvic inflammatory disease), and skin and soft tissue infections in patients with diabetes.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

C. Third generation cephalosporins

1. Due to expanded activity against gram-negative aerobes, 3rd generation cephalosporins are used for the treatment of bacteremia, pneumonia, complicated urinary tract infection, peritonitis, intraabdominal infections, skin and soft tissue infections, bone and joint infections, and meningitis (those that penetrate the CSF) caused by gram-negative bacteria (nosocomial infections). If Pseudomonas aeruginosa is known or suspected, ceftazidime or cefoperazone should be used. If anaerobes are known or suspected, metronidazole or clindamycin should be added.

2. Ceftriaxone is used as a single IM dose for uncomplicated gonorrhea.

3. Cefotaxime and ceftriaxone have good activity against gram-positive aerobes, and may be used for the treatment of infections due to penicillin- resistant Streptococcus pneumoniae (meningitis, pneumonia). Ceftriaxone can be used for the treatment of viridans strep endocarditis in clinically stable patients as outpatient parenteral therapy.

4. Oral third generation cephalosporins are used for the treatment of uncomplicated urinary tract infections, acute otitis media, minor soft tissue infections, and acute sinusitis.

D. Fourth generation cephalosporins

1. Cefepime is used for the treatment of community- and hospital-acquired pneumonia, bacteremia, uncomplicated and complicated urinary tract infections, skin and soft tissue infections, intraabdominal infections gram- negative meningitis, and empiric therapy for febrile neutropenia. Cefepime also has antipseudomonal activity. If anaerobes are known or suspected, metronidazole or clindamycin should be added.

VIII. ADVERSE EFFECTS

A. Hypersensitivity - 5%

1. Reactions include pruritus, rash (maculopapular, erythematous, or morbilliform), urticaria, angioedema, hypotension, vasodilation, shock, and anaphylaxis.

2. Hypersensitivity reactions to cephalosporins occur most frequently in patients with a history of penicillin allergy. The degree of cross-reactivity is 5 to 15%, and clinicians must consider the allergic reaction to penicillin (? IgE mediated) and the degree of cross-reactivity when deciding if a cephalosporin should be used in a patient with a history of allergy to penicillin.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

a. Immediate or accelerated hypersensitivity reactions (anaphylaxis, laryngeal edema, hives, bronchospasm) – avoid other cross-reactive - lactams, such as cephalosporins.

b. Delayed hypersensitivity reactions (rash, pruritus) – give other - lactams with caution keeping in mind the degree of cross-reactivity.

3. Other skin reactions include Stevens-Johnson syndrome, erythema multiforme, toxic epidermal necrolysis, and exfoliative dermatitis.

B. Some cephalosporins have a 5-NMTT side chain (nitromethylthiotetrazole) that confers unique adverse effects.

1. Cephalosporins with the NMTT side chain include cefamandole, cefotetan, cefmetazole, cefoperazone, and moxalactam.

2. Hypoprothrombinemia with or without bleeding due to blocking of enzyme in vitamin K metabolism or reduction of vitamin K producing bacteria in the GI tract. Moxalactam also reduces platelet aggregation that significantly increased the incidence of bleeding.

3. Disulfiram reaction (ethanol intolerance).

C. Hematologic

1. β-lactam-specific cytotoxic IgG or IgM antibodies are developed that bind to circulating WBC or platelets; cause cell lysis when antigen (penicillin) encountered by activation of the complement system

2. Leukopenia, neutropenia or thrombocytopenia - especially in patients receiving long-term (> 2 weeks) therapy

D. Gastrointestinal

1. Transient increases in liver enzymes.

2. Biliary sludging – with ceftriaxone therapy.

3. Nausea, vomiting.

4. Pseudomembranous colitis (Clostridium difficile diarrhea). Some cephalosporins may cause diarrhea that is not due to C. difficile.

E. Precipitation of ceftriaxone with IV calcium products – avoid coadministration.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

F. Other adverse effects include phlebitis; drug fever; interstitial nephritis (rare); neurotoxicity; nonconvulsive status epilepticus (cefepime, ceftazidime).

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

CARBAPENEMS

I. INTRODUCTION

The carbapenem antibiotics, -lactam antibiotics with a carbapenem nucleus, were initially discovered in the mid-1970s. The clinical development of the carbapenems was delayed due to chemical instability and toxicity (nephrotoxicity and neurotoxicity) associated with earlier compounds in this class. Currently, four carbapenem antibiotics are commercially available in the United States: imipenem, the first carbapenem antibiotic, received FDA approval in 1986, meropenem received FDA approval in 1996, ertapenem received FDA approval in 2001, and doripenem received FDA approval in 2007.

II. CHEMISTRY

A. Carbapenems are -lactam antibiotics that contain a -lactam ring fused to a 5- membered ring, like the penicillins. However, the 5-membered ring of the carbapenems contains a carbon atom at position one (hence the name, carbapenem) instead of a sulfur atom, and the addition of a double bond.

B. All carbapenems contain a hydroxyethyl group in the trans configuration at position 6 as compared to an acylamino group in the cis configuration of the penicillins and cephalosporins. This structural difference results in increased antibacterial activity and greater stability against most -lactamase enzymes.

B = β-lactam ring

III. MECHANISM OF ACTION

A. Like other -lactam antibiotics, carbapenem antibiotics display time-dependent bactericidal activity (except against Enterococcus), and cause bacterial cell death by covalently binding to PBPs that are involved in the biosynthesis of bacterial cell walls.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

B. Each carbapenem displays different affinities for specific PBPs, which appear to be genus-specific. The highest binding affinity for imipenem, meropenem and doripenem is PBP-2. C. The carbapenems are zwitterions that are relatively small, which enable them to penetrate the outer membrane of most gram-negative bacteria and gain access to the PBPs more readily than many other -lactam antibiotics.

IV. MECHANISMS OF RESISTANCE

A. Decreased permeability as a result of alterations to outer membrane porin proteins is an important mechanism of resistance in gram-negative bacteria, particularly Pseudomonas aeruginosa.

B. Hydrolysis of carbapenem antibiotics by -lactamase or carbapenemase enzymes. However, all of the carbapenems display intrinsic resistance to nearly all -lactamases (are very stable and not destroyed), including both plasmid- and chromosomally- mediated enzymes.

C. Alterations in PBPs that lead to decreased binding affinity of the carbapenem.

V. SPECTRUM OF ACTIVITY

A. The carbapenems are currently the most broad-spectrum antibiotics, with good activity against many gram positive AND gram-negative aerobes AND anaerobes.

B. Gram-positive aerobes - imipenem and doripenem exhibit good activity; meropenem and ertapenem are generally 2 to 4 times less active than imipenem methicillin-susceptible Staphylococcus aureus (MSSA) penicillin-susceptible Streptococcus pneumoniae Groups A, B, and C streptococci viridans streptococci Enterococcus faecalis only (most strains of E. faecium are resistant)

C. Gram-negative aerobes – the carbapenems display excellent activity against many gram-negative aerobes (doripenem and meropenem are the best, followed by imipenem and ertapenem); differences in susceptibility exist between the agents and are species-dependent; carbapenems display activity against -lactamase producing strains that display resistance to other -lactam antibiotics

E. coli Citrobacter freundii Klebsiella spp. Enterobacter spp. Serratia marcescens Proteus spp. Morganella morganii Providencia spp. Yersinia spp. Acinetobacter spp. (not ertapenem)

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

Neisseria spp. Haemophilus influenzae Moraxella catarrhalis Campylobacter jejuni Salmonella spp. Shigella spp. Pseudomonas aeruginosa (NOT ertapenem) D. Anaerobes – all carbapenems display excellent activity against clinically significant gram-positive and gram-negative anaerobes including:

Gram-positive anaerobes Peptostreptococcus sp. Peptococcus spp. Clostridium perfringens and tetani

Gram-negative anaerobes Bacteroides fragilis Bacteroides vulgatus Bacteroides distasonis Bacteroides thetaiotamicron Bacteroides ovatus Prevotella bivia Fusobacterium spp. Veillonella parvula

E. The carbapenems do NOT have activity against methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative staphylococci, some enterococci, Clostridium difficile, Stenotrophomonas maltophilia, Nocardia, and atypical bacteria.

VI. PHARMACOLOGY – no oral agents at this time

A. Distribution – all carbapenems are widely distributed in various body tissues and fluids including saliva, sputum, aqueous humor, skin, soft tissue, bone, bile, endometrium, heart valves, placenta; pleural, peritoneal, and wound fluids.

1. CSF penetration - only low concentrations of imipenem diffuse into the CSF following IV administration, with CSF concentrations approximately 1 to 10% of concurrent serum concentrations; meropenem penetrates into the CSF better than imipenem and ertapenem, with CSF concentrations up to 52% of simultaneous serum concentrations in patients with inflamed meninges

B. Elimination

1. The major route of elimination of all of the carbapenems is urinary excretion of unchanged drug involving both glomerular filtration and tubular secretion.

a. Imipenem undergoes hydrolysis in the kidney by an enzyme called dihydropeptidase (DHP) to microbiologically inactive and potentially nephrotoxic metabolites. A DHP inhibitor called cilastatin is added to commercially-available preparations of imipenem to prevent renal metabolism and protect against potential nephrotoxicity.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

2. The elimination half-life of imipenem, meropenem and doripenem is approximately 1 hour in patients with normal renal function; the elimination half-life of ertapenem is approximately 4 hours.

3. All carbapenems require dosage adjustment in patients with renal dysfunction and are removed during hemodialysis procedures so they are usually dosed after hemodialysis.

C. Dosing of the carbapenems in patients with normal renal function

Adult Dosage Pediatric Dosage

IMIPENEM 250 mg to 500 mg IV every 6 hours 15 to 25 mg/kg IV every 6 hours (usual dose 500 mg IV every 6 hours) (not recommended)

MEROPENEM 1 to 2 grams IV every 8 hours 20 to 40 mg/kg IV every 8 hours

ERTAPENEM 1 gram IV every 24 hours

DORIPENEM 500 mg IV every 8 hours

VII. CLINICAL USES - are very expensive

A. The carbapenems are very broad-spectrum antibiotics that are typically used for polymicrobial infections where they can be used as monotherapy such as intraabdominal infections or skin and skin structure infections in diabetic patients. Ertapenem does not have activity against Pseudomonas aeruginosa.

B. Empiric therapy for nosocomial infections such as serious lower respiratory tract infections, septicemia, and complicated urinary tract infections, while waiting for the results of culture and susceptibility data. Ertapenem does not have activity against Pseudomonas aeruginosa. Once results of the cultures and susceptibilities are known, therapy is often changed to a less broad spectrum and less costly (and more targeted) antimicrobial agent.

C. Infections due to resistant bacteria, especially those organisms that produce type 1 or class C β-lactamase enzymes.

D. Febrile neutropenia – imipenem or meropenem

E. Meningitis (children) - meropenem

VIII. ADVERSE EFFECTS

A. Hypersensitivity - 3%

16

Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

1. Reactions include rash, fever, pruritus, urticaria, angioedema, hypotension and anaphylaxis.

2. Cross reactivity (5 to 15%) can occur in patients who have a history of hypersensitivity to penicillins, so clinicians must consider the degree of cross reactivity and reaction to penicillin before using a carbapenem in a penicillin- allergic patient.

a. Immediate or accelerated hypersensitivity reactions (anaphylaxis, laryngeal edema, hives, bronchospasm) – avoid other cross-reactive - lactams, such as carbapenems.

b. Delayed hypersensitivity reactions (rash, pruritus) – give other - lactams with caution keeping in mind the degree of cross-reactivity.

B. Gastrointestinal

1. Nausea, vomiting, and diarrhea have been reported in up to 5% of patients receiving carbapenems.

2. Antibiotic-associated pseudomembranous colitis (C. difficile).

C. Central nervous system – direct toxic effect

1. Insomnia, agitation, confusion, dizziness, hallucinations, and depression.

2. Seizures - have been reported in patients receiving imipenem (1.5%), meropenem (0.5%), ertapenem (0.5%), and doripenem (<0.5%).

a. Historically, initial imipenem dosage recommendations were 1 gram every 6 hours without specific guidelines for dose adjustment in renal insufficiency - may have led to the initial increased incidence of seizures. Today, 500 mg every 6 hours is used with dosage adjustments in renal dysfunction, and the incidence of seizures has decreased.

b. Risk factors for the development of seizures during carbapenem therapy include preexisting CNS disorders (e.g. history of seizures, brain lesions, recent head trauma), high doses (> 2 grams imipenem per day), and the presence of renal dysfunction.

D. Other adverse effects associated with carbapenems include thrombophlebitis, neutropenia, thrombocytopenia, transient LFT increases, and yeast infections.

17

Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

MONOBACTAMS

I. INTRODUCTION

Naturally occurring monobactams are produced by various bacteria found in soil, and generally have only weak antibacterial activity. Synthetic monobactams, such as aztreonam, have greater antimicrobial potency and display stability against hydrolysis by some - lactamase enzymes. Currently, aztreonam is the only monobactam antibiotic available in the United States.

II. CHEMISTRY

A. Aztreonam is a synthetic monocyclic, -lactam antibiotic (monobactam). Unlike other currently available -lactam antibiotics that are bicyclic and contain a ring fused to the -lactam ring, aztreonam contains only a -lactam ring with various side chains.

B = β-lactam ring

III. MECHANISM OF ACTION

A. Like bicyclic -lactam antibiotics, aztreonam is bactericidal because of its ability to bind to and inhibit PBPs and ultimately inhibit peptidoglycan synthesis, which is essential for the synthesis, assembly and maintenance of bacterial cell walls.

B. Aztreonam binds preferentially to PBP-3 in aerobic gram-negative bacilli, interfering with cell wall synthesis. Aztreonam has poor affinity for PBPs of gram-positive and anaerobic bacteria.

IV. MECHANISMS OF RESISTANCE

A. Hydrolysis by bacterial -lactamase enzymes - aztreonam is relatively stable against hydrolysis by some plasmid- and chromosomally-mediated -lactamases; aztreonam is hydrolyzed by some -lactamases produced by Klebsiella spp., Enterobacter spp., and Pseudomonas aeruginosa.

18

Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

B. Alteration in outer membrane porin proteins in gram-negative bacteria leading to decreased permeability.

V. SPECTRUM OF ACTIVITY

A. Aztreonam preferentially binds to PBP-3 in gram-negative aerobic bacteria; therefore, aztreonam only has activity against gram-negative aerobes.

1. Gram-positive aerobes - inactive

2. Gram-negative aerobes - aztreonam is active against a wide range of gram- negative aerobes including:

Haemophilus influenzae Moraxella catarrhalis Citrobacter spp. Enterobacter spp. E. coli Klebsiella pneumoniae Proteus spp. Morganella morganii Providencia spp. Serratia marcescens Salmonella spp. Shigella spp. Pseudomonas aeruginosa

3. Anaerobes - inactive

VI. PHARMACOLOGY – only available IV

A. Distribution - Aztreonam is widely distributed into body tissues and fluids including skeletal muscle, adipose tissue, skin, bone, gallbladder, liver, lungs, prostatic tissue, endometrium, sputum, bronchial secretions, aqueous humor, bile, pleural fluid, peritoneal fluid, and synovial fluid. Aztreonam DOES penetrate into the CSF, especially in the presence of inflamed meninges.

B. Elimination - Aztreonam is excreted principally in the urine as unchanged drug. The half- life of aztreonam is 1.3 to 2.2 hours in patients with normal renal function. Doses need to be adjusted in patients with renal insufficiency, and aztreonam is removed during hemodialysis.

C. Dosing in normal renal function

Adults: 0.5 to 2 grams IV every 8 hours Pediatric: 30 to 50 mg/kg IV every 8 hours

19

Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

VII. CLINICAL USES

A. Aztreonam can only be used for the treatment of infections caused by gram-negative aerobes such as complicated and uncomplicated urinary tract infections, lower respiratory tract infections, meningitis, bacteremia, skin and skin structure infections, intraabdominal infections, and gynecologic infections caused by susceptible gram- negative aerobes. If anaerobes are known or suspected, metronidazole or clindamycin should be added.

B. Aztreonam is especially useful for the treatment of gram-negative infections in patients with a history of a severe penicillin allergy.

VIII. ADVERSE EFFECTS

A. Hypersensitivity - rash, pruritus, urticaria, angioedema, anaphylaxis (rare). Studies in rabbits and humans suggest that antibodies directed against penicillin show negligible cross-reactivity with aztreonam. Because of a low to negligible incidence of cross- reactivity, aztreonam can be used in a patient with a history of penicillin allergy.

B. Gastrointestinal - diarrhea, nausea, vomiting in 1 to 2% of patients

C. Other: neutropenia, thrombocytopenia, eosinophilia, transient LFT increases, phlebitis, drug fever

20 Antibiotics vs Gram-Positive Organisms Gail Reid, MD [email protected]

Vancomycin Linezolid Daptomycin

Mycozonook.com

Learning Objectives

• Understand Mechanisms of Action • Understand Mechanisms of Resistance • Learn Spectrum of Activity • Understand Pharmacokinetic Characteristics • Know Major Clinical Uses • Know Major Adverse Reactions • Know Major Drug Interactions

• Staph •Strep •Listeria • Clostridium • Bacillus • Actinomyces

Bacteriainphotos.com; eyepathologist.com Vancomycin

• Commercially-available since 1956 • Underwent extensive purification → ↓ AEs • Clinical use ↓ with introduction of antistaphylococcal penicillins • ↑ Use due to more MRSA and PRSP • Complex tricyclic glycopeptide produced by Streptomyces orientalis, MW = 1500 Da

Beerclubnj.com

Vancomycin Mechanism of Action

• Inhibits bacterial cell wall synthesis at a site different than -lactams • Inhibits synthesis and assembly of the second stage of cell wall synthesis • Binds firmly to D-alanyl-D-alanine portion of cell wall precursors to prevent cross-linking and further elongation of peptidoglycan; weakens cell wall • Time-dependent bactericidal activity; slowly kills bacteria (static against Enterococcus)

Vancomycin

cid.oxfordjournals.co Vancomycin Mechanism of Resistance

• Resistance in VRE and VRSA due to modification of D-alanyl-D-alanine binding site of peptidoglycan  Terminal D-alanine replaced by D-lactate  Loss of critical hydrogen bond  Loss of antibacterial activity  3 phenotypes - vanA, vanB, vanC • VISA – thickened cell wall

Vancomycin Spectrum of Activity

Gram-positive bacteria  Methicillin-Susceptible AND Methicillin-Resistant S. aureus and coagulase-negative staphylococci*  Streptococcus pneumoniae (including PRSP*), viridans streptococcus, Group streptococcus  Enterococcus spp.  Corynebacterium, Bacillus. Listeria, Actinomyces  Clostridium spp. (including C. difficile*), Peptococcus, Peptostreptococcus No activity vs gram-negative organisms

* = target organisms

Vancomycin Pharmacology

• Time-dependent bactericidal activity • Interpatient variability in Vd and Cl also exists for vancomycin • Absorption  Absorption from GI tract is negligible after oral administration, except in patients with colitis  Must use intravenous therapy for treatment of systemic infections Vancomycin Pharmacology

Distribution  Widely distributed into body tissues and fluids, including adipose tissue - use TBW for dosing  Variable penetration into CSF, even with inflamed meninges  Takes one hour to distribute from plasma into tissue compartment (peak drawn later)  Normal Vd = 0.5 - 0.65 L/kg  Vd increased in neonates

Vancomycin Pharmacology

Elimination  Primarily eliminated unchanged by the kidney via glomerular filtration  Elimination half-life depends on renal function  6 to 8 hours with normal renal function  Progressively increases with degree of renal dysfunction (7-14 days in pts with ESRD)  NOT removed by hemodialysis Vancomycin Serum Concentration Monitoring

• Lack of well-controlled studies relating serum concentrations to efficacy or toxicity • Variability in Vd and Cl may necessitate concentration monitoring in some patients • Peak - should be drawn 60 minutes after a the end of infusion; falsely elevated if drawn too early (during distribution phase)  Target = 30 to 40 mcg/ml • Trough - prior to next dose  Target = 5 to 15 mcg/ml

Vancomycin Dosing • Consider differences in Vd and Cl when determining dose for each patient • Several dosing nomograms are available • Adults  Normal renal function: 10 - 15 mg/kg every 12 hours (typically 1 to 1.5 grams)  Impaired renal function: 10 - 15 mg/kg/dose with interval based on renal function  Use TBW for dosing, unless > 200kg • Neonates and children  10 - 15 mg/kg/dose with interval based on age

Vancomycin Clinical Uses

• Infections due to methicillin-resistant staph including bacteremia, empyema, endo- carditis, peritonitis, pneumonia, skin and soft tissue infections, osteomyelitis, meningitis • Serious gram-positive infections in -lactam allergic patients • Infections caused by multidrug resistant bacteria (PRSP) • Endocarditis or surgical prophylaxis in select cases • Oral vancomycin for moderate to severe C. difficile colitis Vancomycin Adverse Effects

Red-Man Syndrome  Flushing, pruritus, erythematous rash on face, neck, and upper torso within 5 to 15 minutes of starting infusion  Related to RATE of intravenous infusion; doses should be infused over at least 60 minutes (no faster than 15 mg per minute)  Resolves spontaneously after discontinuation  May lengthen infusion (over 2 to 3 hours) or pre-treat with antihistamines in some cases

Vancomycin Adverse Effects

• Nephrotoxicity and Ototoxicity  Rare with vancomycin monotherapy, more common when administered with other nephro- or ototoxins  Risk factors include renal impairment, prolonged therapy, high doses, ? high serum concentrations, use of other nephro- or ototoxins • Dermatologic - rash • Hematologic - neutropenia and thrombo- cytopenia with prolonged therapy • Thrombophlebitis, interstitial nephritis

Oxazolidinones

• Linezolid (Zyvox®) is the first FDA approved agent (2000) PO and IV • Developed in response to need for antibiotics with activity against resistant gram-positives (VRE, MRSA, VISA) • Linezolid is a semisynthetic oxazolidinone, which is a structural derivative of earlier agents in this class Linezolid Mechanism of Action • Binds to the 50S ribosomal subunit near the surface interface of 30S subunit – causes inhibition of 70S initiation complex (unique binding site), which inhibits protein synthesis • Bacteriostatic (cidal vs Strep pneumoniae) Mechanism of Resistance • Alterations in ribosomal binding sites - rare • Cross-resistance with other protein synthesis inhibitors is unlikely

Linezolid

Chm.bris.ac.uk;

Linezolid Spectrum of Activity Gram-Positive Bacteria  Methicillin-Susceptible, Methicillin-Resistant AND Vancomycin-Resistant Staph aureus* and coagulase-negative staphylococci  Streptococcus pneumoniae (including PRSP*), viridans streptococcus, Group streptococcus  Enterococcus faecium AND faecalis (including VRE)*  Bacillus. Listeria, Clostridium spp. (except C. difficile), Peptostreptococcus, P. acnes Gram-Negative – inactive Atypical Bacteria (some activity)  Mycobacteria

* = target organisms Linezolid Pharmacology

• Time-dependent bactericidal activity • Post Abx Effect for Gram-Positives  3 to 4 hours for S. aureus and S. pneumoniae  0.8 hours for Enterococcus • Absorption – 100% bioavailable • Distribution – readily distributes into well- perfused tissue; CSF penetration  30% • Elimination – both renally and nonrenally, but primarily metabolized; t½ is 4.4 to 5.4 hours; no adjustment for RI; removed by HD

Linezolid Clinical Uses and Dosing

• Very expensive - $75 to $140 per day (600 mg every 12 hours IV or PO) • Use reserved for serious/complicated infections caused by resistant gram-positive bacteria:  VRE bacteremia, NOT urinary tract infections  Complicated skin and soft tissue infections due to MSSA, MRSA or Streptococcus pyogenes  Nosocomial pneumonia due to MRSA • Data is accumulating in the treatment of serious infections due to MRSA or VRE (endocarditis, meningitis, osteo); catheter-related bacteremia Linezolid Drug Interactions

• Has potential to interact with adrenergic or serotonergic agents

 Enhancement of pressor response to agents such as dopamine or epinephrine

 Serotonin syndrome with SSRIs/MAOIs – hyperpyrexia, diarrhea, cognitive dysfunction, restlessness, seizures, coma . May need two week washout period

Linezolid Adverse Effects

• GI – nausea, vomiting, diarrhea (6 to 8 %), lactic acidosis • Headache – 6.5% • Peripheral neuropathy • Thrombocytopenia or anemia: > 2-4%  Most often with treatment > 10- 14 days  Therapy should be discontinued – counts will return to normal

Lipopeptides

• Daptomycin (Cubicin) is a cyclic lipopeptide antibiotic with activity vs resistant gram-positives (VRE, MRSA, VISA) • FDA-approved September 2003 • Derived from Streptomyces roseosporus • Large molecular weight = 1620 Da Daptomycin

Mechanism of Action • Binds to bacterial membranes → rapid depolarization of membrane potential → inhibition of protein, DNA, and RNA synthesis • Concentration-dependent bactericidal activity Mechanism of Resistance • Rarely reported in VRE and MRSA due to altered cell membrane binding

Daptomycin

Sciencedirect.com

Daptomycin Spectrum of Activity

Gram-Positive Bacteria  Methicillin-Susceptible, Methicillin-Resistant AND Vancomycin-Resistant Staph aureus* and coagulase-negative staphylococci  Streptococcus pneumoniae (including PRSP*), viridans streptococcus, Group streptococcus  Enterococcus faecium AND faecalis (including VRE)* Gram-Negatives – inactive

* = target organisms Daptomycin Pharmacology

• Concentration-dependent bactericidal activity •IV • Distribution – readily distributes into well- perfused tissue; protein binding = 90% • Elimination – excreted primarily by the kidneys (78%); t½ is 7.7 to 8.3 hours in normal renal function; dosage adjustments are required in the presence of RI; not removed by HD

Daptomycin Clinical Uses and Dosing

• Very expensive - $165 per day (6 mg/kg/day) • Use reserved for serious/complicated infections caused by resistant bacteria:  Complicated skin and soft tissue infections due to MSSA, MRSA, or Streptococcus pyogenes  Bacteremia due to Staphylococcus aureus  Data accumulating in treatment of serious infections due to MRSA or VRE (endocarditis, meningitis, osteo); catheter-related bacteremia • Daptomycin should NOT be used in the treatment of pneumonia

Daptomycin

• Adverse Effects  Gastrointestinal – nausea, diarrhea  Headache  Injection site reactions  Rash  Myopathy and CPK elevation - <2% • Drug Interactions  HMG CoA-reductase inhibitors – may lead to increased incidence of myopathy Questions? Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

FLUOROQUINOLONES

Date: October 23 at10:30 am

Suggested Reading Assignment: Walker RC. The fluoroquinolones. Mayo Clinic Proceedings 1999;74:1030-7.

Learning Objectives:

1. Describe the mechanism of action of the fluoroquinolones. 2. Describe the mechanisms by which bacteria develop resistance to the fluoroquinolone antibiotics. 3. List the spectrum of activity of the older and newer/respiratory fluoroquinolones. List the fluoroquinolones that have the best activity against Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, atypical bacteria, and anaerobes. 4. Describe the major pharmacokinetic differences between the fluoroquinolones in terms of oral bioavailability, half-life, dosing interval, penetration into the CSF, route of excretion, necessity for dosage adjustment in renal insufficiency, and removal by hemodialysis. 5. Discuss the main clinical uses of ciprofloxacin, levofloxacin, and moxifloxacin. 6. List the major adverse effects associated with fluoroquinolone therapy. 7. Explain the major drug interactions that may occur with the fluoroquinolone antibiotics. 8. Name the fluoroquinolones that are currently available in the US, including the dosage forms that are available.

Drugs Covered in this Lecture:

Ciprofloxacin, Levofloxacin, Moxifloxacin, Gemifloxacin

1 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

FLUOROQUINOLONES

I. INTRODUCTION

The fluoroquinolone antibiotics are a novel group of synthetic antibiotics developed in response to the need for antibiotics with activity against resistant bacteria. All of the quinolones available today are structural derivatives of the original prototype agent of this class, nalidixic acid. The usefulness of nalidixic acid was hindered by the rapid development of bacterial resistance (even during therapy) and limited therapeutic utility. The introduction of the fluorinated 4-quinolones (hence the name fluoroquinolones {FQs}: ciprofloxacin, ofloxacin, levofloxacin, gatifloxacin, moxifloxacin, gemifloxacin) represents a particularly important therapeutic advance as these agents have broad antimicrobial activity, excellent oral bioavailability, extensive tissue penetration, and relatively long serum half-lives. Like other antibiotic classes, the main disadvantage of the FQs is the emergence of resistance in certain organisms.

II. CHEMISTRY

A. Currently available fluoroquinolones have two six-membered rings containing a nitrogen at position 1, a carboxylic acid moiety at position 3, a carbonyl group at position 4, a fluorine at position 6, and a piperazine moiety or other group at position 7.

Responsible for R O interaction with Enhances tissue divalent and trivalent penetration and cations binding at topoisomerases F COOH

R7 X N l Piperazine group at R7 R provides activity against Pseudomonas

III. MECHANISM OF ACTION

A. The FQs have a unique mechanism of action that includes inhibition of DNA synthesis by binding to and inhibiting bacterial topoisomerases, which are enzymes needed for maintaining cellular DNA in an appropriate state of supercoiling in both the replicating and nonreplicating regions of the bacterial chromosome.

2 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

B. The FQs target bacterial DNA gyrase (topoisomerase type II) and topoisomerase IV:

1. Inhibition of DNA gyrase prevents the relaxation of positively supercoiled DNA that is required for normal transcription and replication. The FQs form a stable complex with DNA and DNA gyrase, which blocks the replicating fork leading to a sudden and lethal cessation of DNA replication. For many gram-negative bacteria, DNA gyrase is the primary target of the FQs.

2. Inhibition of topoisomerase IV interferes with separation of replicated chromosomal DNA into the respective daughter cells during cell division that are the product of DNA replication, causing a cessation in DNA replication. For many gram-positive bacteria (S. aureus), topoisomerase IV is the primary target of the FQs.

C. The FQs display concentration-dependent bactericidal activity.

IV. MECHANISMS OF RESISTANCE

A. Altered binding sites – chromosomal mutations in the genes that code for the subunits of topoisomerase IV or DNA gyrase lead to decreased binding affinity of the FQs to these target sites.

1. S. aureus and P. aeruginosa require only a single mutation in the genes encoding for the topoisomerases to become resistant.

2. E. coli and S. pneumoniae often require more than one mutation to become resistant to the newer FQs.

B. Expression of active efflux – efflux pump is turned on that enhances the transfer of FQs out of the cell; reported in P. aeruginosa and S. pneumoniae.

C. Altered cell wall permeability – chromosomal mutations cause decreased expression of porin proteins that are responsible for FQ transit inside the cell leading to decreased FQ accumulation within the cell (rare).

D. Cross-resistance is usually observed between the FQs.

V. SPECTRUM OF ACTIVITY – older (ciprofloxacin) versus newer/respiratory FQs (levofloxacin, moxifloxacin, gemifloxacin)

A. Gram-positive aerobes – ciprofloxacin has poor activity against gram-positive bacteria; the newer FQs (levofloxacin, trovafloxacin, gatifloxacin, moxifloxacin, gemifloxacin) have enhanced activity against gram-positive bacteria

. Methicillin-susceptible S. aureus (not MRSA) . Streptococcus pneumoniae (including PRSP – except ciprofloxacin)

3 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

. Group and viridans streptococci, Enterococcus spp. – limited activity

B. Gram-negative aerobes – some FQs have excellent activity against Enterobacteriaceae (ciprofloxacin=levofloxacin>gatifloxacin>gemifloxacin, moxifloxacin), H. influenzae, M. catarrhalis, and Neisseria species

Haemophilus influenzae Moraxella catarrhalis Citrobacter spp. Enterobacter spp. Escherichia coli Klebsiella pneumoniae Proteus spp. Morganella morganii Providencia spp. Serratia marcescens Salmonella spp. Shigella spp. Campylobacter spp Neisseria spp. Pseudomonas aeruginosa (cipro ≥ levo > gati; NOT moxi)

C. Anaerobes – trovafloxacin had adequate activity against anaerobes including Bacteroides fragilis; moxifloxacin has some activity

D. Atypical Bacteria – most FQs are extremely active against Legionella, Chlamydophila, Mycoplasma, and Ureaplasma

E. Other Organisms – have activity against Mycobacterium tuberculosis (levo, moxi) and Bacillus anthracis (cipro, levo)

VI. PHARMACOLOGY (see PK chart page 5)

A. FQs exhibit concentration-dependent bactericidal activity (AUC/MIC {30 to 50 for S. pneumoniae; 100 to 125 for gram-negatives} or Peak/MIC correlate with clinical efficacy) and display a PAE against both gram-positive (2 hours) and gram-negative aerobic bacteria (2 to 4 hours).

B. Absorption

1. FQs are well absorbed after oral administration (except for norfloxacin, F = 50%); oral bioavailability is 70 to75% for ciprofloxacin and > 90% for levofloxacin and moxifloxacin – allows for early conversion to oral therapy.

2. Tmax is achieved within 1 to 2 hours; coingestion with food delays peak serum concentrations.

C. Distribution

1. Most of the FQs display extensive tissue penetration obtaining therapeutic concentrations in the prostate, liver, lung, bronchial mucosa, sputum, bile, saliva, skin and soft tissue, bone and into alveolar macrophages.

4 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

2. Most FQs achieve high urinary concentrations (except for moxifloxacin, trovafloxacin, and gemifloxacin) making them useful for the treatment of urinary tract infections and prostatitis.

3. FQs achieve minimal penetration into the CSF.

D. Elimination

1. FQs are eliminated by various pathways

a. Renal elimination – levofloxacin, ofloxacin, and gatifloxacin are eliminated primarily by the kidney (glomerular filtration and tubular secretion); dosage adjustments of these agents are necessary in the presence of renal insufficiency

b. Hepatic metabolism and elimination – trovafloxacin and moxifloxacin are primarily metabolized

c. Ciprofloxacin and gemifloxacin undergo both renal and hepatic elimination; doses of both agents should be adjusted in the presence of renal insufficiency

d. NONE of the FQs are removed during hemodialysis

PHARMACOKINETIC TABLE Agent Dose F Cmax AUC Half-life Protein % Renal (%) (g/ml) (mg*hr/ml) (hours) Binding Excretion (%) Norfloxacin 400 mg PO 50 1.5 13.6 3.3 15 40 Ciprofloxacin 500 mg PO 70 2.4 29 4 25 60 400 mg IV 4.6 5 - 6 Ofloxacin 400 mg PO 95 4.6 35 4 - 5 25 90 400 mg IV 5.5 6 Levofloxacin 500 mg PO 99 5.7 45 – 50 6 - 8 25 90 500 mg IV 6.4 6 - 8 750 mg PO 8.6 91 750 mg IV 12.1 108 Gatifloxacin 400 mg PO 96 3.4 32 6.5 - 8.4 18 80 No longer available 400 mg IV 4.6 Moxifloxacin 400 mg PO 90 4.3 39 - 48 9.2 50 20 400 mg IV 4.2 Gemifloxacin 320mg PO 71 1.6 9.9 7 60 - 70 36

5 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

E. DOSING Parenteral (IV) Oral

CIPROFLOXACIN (Cipro) 200 to 400 mg q8-12h 250 to 750 mg BID OFLOXACIN (Floxin) 400 mg q12h 400 mg q12h LEVOFLOXACIN (Levaquin) 250 to 750 mg QD 250 to 750 mg QD TROVAFLOXACIN (Trovan) 200 mg QD 200 mg QD MOXIFLOXACIN (Avelox) 400 mg QD 400 mg QD NORFLOXACIN (Noroxin) 400 mg q12h GEMIFLOXACIN (Factive) 320 mg QD

VII. CLINICAL USES

A. Community-acquired pneumonia – levofloxacin, moxifloxacin, and gemifloxacin

B. Acute exacerbations of chronic bronchitis and sinusitis – ciprofloxacin, levofloxacin, moxifloxacin, and gemifloxacin

C. Bacterial exacerbations in cystic fibrosis (P. aeruginosa) - ciprofloxacin

D. Nosocomial pneumonia – ciprofloxacin and levofloxacin

E. Urinary tract infections (cystitis, pyelonephritis) – ciprofloxacin, levofloxacin; norfloxacin (cystitis only)

F. Chronic Bacterial Prostatitis – ciprofloxacin and levofloxacin

G. Osteomyelitis - ciprofloxacin

H. Other – intraabdominal infections (ciprofloxacin or levofloxacin with metronidazole, moxifloxacin alone); traveler’s diarrhea (ciprofloxacin, norfloxacin); tuberculosis (ciprofloxacin, levofloxacin, moxifloxacin); STDs; febrile neutropenia prophylaxis and treatment (ciprofloxacin); eye infections

VIII. ADVERSE EFFECTS – many FQs have been removed from the market due to adverse effects; FQs still available are well tolerated.

A. Gastrointestinal (5%) – nausea, vomiting, diarrhea, dyspepsia, Clostridium difficile colitis

B. CNS – headache, confusion, agitation, insomnia, dizziness (trovafloxacin 11%); rarely hallucinations and seizures

6 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

C. Hepatotoxicity – transaminase elevation; trovafloxacin was associated with 140 cases of severe liver injury and 14 cases of fulminant liver failure, use was restricted to the treatment of severe infections in hospitalized patients or patients in LTCF where therapy could be closely monitored – now withdrawn from market; moxifloxacin has also been associated with a few cases of liver failure

D. Phototoxicity – highest incidence with earlier FQs including lomefloxacin, sparfloxacin and enoxacin (agents with an additional fluorine or chlorine at position 8); patients are required to avoid exposure to sunlight or UV light

E. Cardiac – FQs may cause slight prolongation in QTc interval, excessive prolongation can lead to Torsades; most significant with sparfloxacin and grepafloxacin (both removed from the market); several case reports of Torsades with ciprofloxacin, levofloxacin, gatifloxacin and moxifloxacin; FQs should be used with caution in patients with hypokalemia, concomitant use of class III antiarrhythmics (amiodarone, sotalol), preexisting QTc prolongation

F. Articular Damage – arthropathy (articular cartilage damage, arthralgias and joint swelling) observed in young experimental animals led to the contraindication in pediatric patients and the warning to avoid their use in pregnant or breastfeeding patients; FQs have been used in a substantial number of pediatric patients without apparent arthropathy (risk versus benefit)

G. Tendonitis and Tendon Rupture – especially in patients over 60 years of age receiving corticosteroids, or who have undergone a renal, heart or lung transplant; patient should avoid exercise if tendon pain develops while on therapy

H. Other: allergic reactions (rare), dysglycemias (gatifloxacin removed from market)

IX. DRUG INTERACTIONS

A. Divalent and trivalent cations (Zinc, Iron, Ca, Al, Mg– including antacids, ddI, Sucralfate, enteral feeds) may impair the absorption of ANY ORAL fluoroquinolones through chelation leading to clinical failure; doses should be administered at least 2 to 4 hours apart (tube feedings must be stopped for several hours surrounding FQ administration); give FQ first

B. Warfarin – idiosyncratic interaction leading to increased prothrombin time and potential bleeding; has been reported with most FQs

C. Theophylline – inhibition of theophylline metabolism leading to increased serum theophylline concentrations and potential toxicity; may occur with ciprofloxacin, but does not occur with levofloxacin, gatifloxacin or moxifloxacin

D. Cyclosporine – ciprofloxacin may inhibit cyclosporine metabolism leading to increased cyclosporine levels and potential toxicity

7 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

METRONIDAZOLE (Flagyl) – IV, PO, topical

Chapter 53: Antiprotozoal Drugs. In: Katzung, BG, ed. Basic and Clinical Pharmacology, 11th edition, McGraw-Hill, New York, NY, 2007.

Kasten MJ. Clindamycin, metronidazole, and chloramphenicol. Mayo Clinic Proceedings 1999;74:825-33.

Learning Objectives:

1. Describe the mechanism of action and mechanisms of resistance of metronidazole. 2. List the spectrum of activity of metronidazole, with special emphasis on their activity against anaerobes and Clostridium difficile. 3. Describe the pharmacokinetic characteristics of metronidazole with respect to oral bioavailability, distribution into the central nervous system, route of elimination, removal by hemodialysis, and dosage adjustment in end-organ dysfunction. 4. List the major clinical uses of metronidazole. 5. List the major adverse effects associated with metronidazole therapy. Describe patient counseling with regard to alcohol consumption during metronidazole therapy. 6. List the major drug interactions associated with metronidazole therapy.

Drugs Covered in this Lecture:

Metronidazole

I. INTRODUCTION

Metronidazole is a synthetic nitroimidazole antibiotic originally recognized to display potent activity against certain protozoa including Trichomonas, Giardia, and Entamoeba. Studies conducted over a decade later revealed that metronidazole had extremely useful clinical activity against a wide variety of gram-positive and gram-negative anaerobic pathogens. Metronidazole is now considered one of the most useful agents in the treatment of anaerobic and polymicrobial infections in the US.

II. CHEMISTRY

A. Metronidazole was derived from azomycin by chemical synthesis and biological testing. Its chemical name is 1-(-hydroxyethyl)-2-methyl-5-nitroimidazole.

1 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

With permission from: Katzung’s Basic and Clinical Pharmacology, 10th edition, 2007, page 857

III. MECHANISM OF ACTION

A. Metronidazole is a prodrug that is activated by a reductive process. Its selective toxicity towards anaerobic and microaerophilic bacteria is due to the presence of electron transport components such as ferredoxins within these bacteria. Ferredoxins are small Fe-S proteins that donate electrons to metronidazole to form a highly reactive nitro radical anion.

B. These short-lived activated metabolites damage bacterial DNA (inhibit nucleic acid synthesis), and subsequently cause cell death – metronidazole is rapidly bactericidal in a concentration-dependent manner.

C. Metronidazole is catalytically recycled when loss of the electron from the active metabolite regenerates the parent compound.

D. Increased levels of oxygen inhibit metronidazole-induced cytotoxicity since oxygen competes with metronidazole for generated electrons. IV. MECHANISM OF RESISTANCE

A. Clinical resistance to metronidazole is well documented for Trichomonas, Giardia, and a variety of anaerobic bacteria, but is relatively uncommon.

1. Altered growth requirements – organism grows in higher local oxygen concentrations causing decreased activation of metronidazole and futile recycling of the active drug

2. Altered levels of ferredoxin – reduced transcription of the ferredoxin gene

V. SPECTRUM OF ACTIVITY

2 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

A. Metronidazole is extremely active against a wide variety of anaerobic protozoal parasites and anaerobic bacteria. It is the antianaerobic agent most reliably active against Bacteroides fragilis.

B. Gram-negative anaerobes – highly active against cocci and bacilli

Bacteroides fragilis Bacteroides distasonis, ovatus, thetaiotamicron, bivius (B. fragilis group DOT organisms) Fusobacterium Prevotella spp. Helicobacter pylori (an obligate anaerobe)

C. Gram-positive anaerobes – active against cocci (variably) and sporulating bacilli

Clostridium spp. (including Clostridium difficile)

C. Other organisms

Trichomonas vaginalis Entamoeba histolytica Giardia lamblia Gardnerella vaginalis

E. Metronidazole is inactive against all common aerobic and facultatively anaerobic bacteria.

VI. PHARMACOLOGY

A. Absorption

1. Metronidazole is rapidly and almost completely absorbed after oral administration, achieving peak concentrations within 0.25 to 3 hours after administration.

2. Food does not affect the absorption of metronidazole, but may delay the Tmax.

3. Serum concentrations are similar after equivalent intravenous and oral doses. Rectal absorption is adequate but delayed, and vaginal absorption is minimal.

3 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

B. Distribution

1. Metronidazole is well distributed into body tissues and fluids, including vaginal secretions, seminal fluids, saliva, and breast milk. Repeated dosing results in some accumulation of the drug.

1. Metronidazole DOES penetrate into the CSF and brain tissue achieving 50 to 100% of simultaneous serum concentrations in the CSF depending on the degree of meningeal inflammation.

C. Metabolism/Elimination

1. Metronidazole is metabolized by the liver to several active metabolites. Metabolism accounts for over 50% of the systemic clearance of metronidazole.

2. Metronidazole and its metabolites are primarily excreted in the urine; only 10% is recovered as unchanged drug in the urine; 6-15% of a dose is excreted in the feces.

2. The elimination half-life in normal renal and hepatic function is 6 to 8 hours for the parent drug, and 12 to 15 hours for some metabolites. The half-life is prolonged in the presence of renal or hepatic dysfunction, so that dosage adjustments are required.

3. Metronidazole is removed during hemodialysis.

VII. CLINICAL USES, DOSAGES, AND ADMINISTRATION – available orally as 250mg and 500 mg tablets; 500 mg for parenteral use; intravaginal gel

A. Infections due to anaerobes (including serious infections) such as skin and soft tissue infections, bone and joint infections, intraabdominal and pelvic infections or abscesses, brain abscesses, diabetic foot infections, etc. Many serious anaerobic infections are polymicrobial, and additional agents are necessary for coverage of other causative organisms (aerobes).

1. Oral: 250 mg to 500 mg every 6 to 8 hours

2. Parenteral: typical adult dose is 500 mg every 6 hours; maximum dose is 4 grams daily

4 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

B. Pseudomembranous colitis due to Clostridium difficile – DRUG OF CHOICE

1. Oral metronidazole is the drug of choice for mild to moderate C. difficile colitis because it is less expensive than oral vancomycin with similar treatment outcomes and less impact on microbial ecology in the intestinal tract.

2. Oral or parenteral therapy may be used: 250 mg to 500 mg every 6 to 12 hours

C. Bacterial vaginosis due to Gardnerella vaginalis – oral (500 mg twice daily for 7 days) or intravaginal therapy (5 g twice daily for 5 days)

D. Trichomonas vaginalis – 2 grams orally as a single dose; 500 mg PO twice daily for 5 days; 250 mg PO every 8 hours for 7 days

E. Amebiasis (intestinal or extraintestinal) – 750 mg PO or IV every 8 hours for 10 days

F. Other: H. pylori (250 mg to 500 mg PO every 8 hours with other meds); Crohn’s diseases (intestinal bacterial overgrowth); acne rosacea; gingivitis

VIII. ADVERSE EFFECTS

A. Gastrointestinal – nausea, diarrhea, anorexia, metallic taste, stomatitis, pancreatitis

B. Central nervous system – most serious; rare unless large doses are utilized or therapy is prolonged

1. Seizures, encephalopathy, cerebellar dysfunction, peripheral neuropathy

2. Use with caution in patient with CNS disorders

3. If neurologic symptoms develop, the drug should be discontinued immediately

C. Other: reversible neutropenia, dark brown urine, local vaginal reactions

D. Mutagenicity and Carcinogenicity

1. Carcinogenic in rodents, especially female rats; concern about the promotion of cancer in humans (long term effects of high-dose prolonged therapy have not been studied)

2. Metronidazole may be teratogenic – should be avoided during the first trimester and during breastfeeding

5 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

IX. DRUG INTERACTIONS

Drug Interaction

Warfarin Increased anticoagulant effect Alcohol Disulfiram reaction Phenytoin Increased phenytoin concentrations Lithium Increased lithium concentrations Phenobarbital Decreased metronidazole concentrations Rifampin Decreased metronidazole concentrations

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Miscellaneous Antibiotics: Tetracyclines, Sulfonamides, Chloramphenicol, UTI agents

Gail Reid, M.D. Infectious Diseases October 25, 2012

Lecture Objectives

Identify the key characteristics of the tetra- cyclines, glycylcyclines, sulfonamides, chloramphenicol and urinary tract agents with respect to:  Mechanism of Action  Mechanisms of Resistance  Spectrum of Activity  Pharmacology  Clinical Uses  Major Adverse Effects  Drug Interactions

Tetracyclines and Glycylcyclines

• Tetracyclines were originally discovered in the 1950s through systematic screening of soil samples  Streptomyces aureofaciens  Chlortetracycline • First Generation  Tetracycline • Second Generation  Doxycycline, Minocycline

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Micsgmjournals.org

Tetracyclines and Glycylcyclines

• Glycylcyclines  Minocycline derivatives  Structural modifications to improve spectrum of activity and overcome resistance mecanisms • Tigecycline (Tygacil®)

Tigecycline Structure

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Tetracyclines/Glycylcyclines Mechanism of Action  Reversibly binds to the 30S ribosomal subunit . Inhibit the binding of aminoacyl transfer-RNA to the acceptor (A) site on the mRNA-ribosomal complex, which prevents addition of amino acid residues on elongating peptide chain  Bacteriostatic . Bactericidal when present at high concentrations against very susceptible organisms

Tetracycline

faculty.ccbcmd.edu

Tetracyclines/Glycylcyclines • Mechanisms of Resistance Acquisition of genes on mobile elements • Efflux Pumps  accumulation of tetracycline within bacteria • Ribosomal protection proteins • Cytoplasmic proteins that protects ribosomes from 1st and 2nd generation tetracyclines • Enzymatic inactivation • Cross-resistance observed between tetracyclines, except for minocycline • Tigecycline resistant to these mechanisms

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Tetracyclines In Vitro Spectrum of Activity

Gram-Positive Aerobes

• Staphylococcus aureus (primarily MSSA) • Streptococcus pneumoniae – PSSP (doxycycline – 83% susceptible) • Bacillus spp, Listeria spp, Nocardia spp

Tetracyclines In Vitro Spectrum of Activity

Gram-Negative Aerobes • N. gonorrhea and meningitidis • Haemophilus influenzae (90% susceptible) • Haemophilus ducreyi (chancroid) • Campylobacter jejuni • Helicobacter pylori • Vibrio cholerae, Vibrio vulnificus

• Pseudomonas pseudomallei

Tetracyclines In Vitro Spectrum of Activity

Anaerobes Actinomyces Propionibacterium Miscellaneous Bacteria Bartonella, Bordetella, Brucella, Pasteurella Legionella, Chlamydophila, Chlamydia, Mycoplasma, Ureaplasma Borrelia, Treponema, Leptospira Rickettsia, Coxiella Mycobacterium fortuitum

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Tigecycline Spectrum of Activity Gram-Negative Aerobes • Acinetobacter baumannii • Aeromonas hydrophila • Citrobacter spp. • Escherichia coli • Klebsiella spp. • Serratia marcescens • Stenotrophomonas maltophilia • NOT Proteus spp or Pseudomonas aeruginosa Anaerobes • Clostridium perfringens, Bacteroides spp

Tigecycline Spectrum of Activity Gram-Positive Aerobes • Staphylococcus aureus • MSSA, MRSA • Enterococcus spp • VRE, VSE

• NOT for bacteremias or UTIs

Tetracyclines/Glycylcyclines Pharmacology

Absorption  Only doxycycline is available PO and IV; tigecycline is only available IV  Tetracycline and demeclocycline F = 60 to 80%  Doxycycline and minocycline F = 90 to 100%  Absorbed best on an empty stomach  Absorption impaired by di- and trivalent cations Distribution  Widely distributed with good penetration into synovial fluid, prostate, seminal fluid  Minimal CSF penetration

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Tetracyclines/Glycylcyclines Pharmacology Elimination  Demeclocycline/tetracycline - excreted unchanged in the urine . dosage adjustment required in renal insufficiency . Tetracycline half-life = 6 to 12 hours; demeclocycline half- life = 16 hours  Doxycycline, minocycline (metab) and tigecycline (biliary) - excreted mainly by non-renal routes . Half-lives = 16-18 hours (doxy, mino); 27-42 hours (tige) – yet they are all dosed every 12 hours! . Do NOT require dosage adjustment in the presence of renal insufficiency. Adjust tigecycline with liver disease  Tetracyclines/tigecycline are minimally removed during hemodialysis

The Clinical Uses of Tetracyclines/Glycylcyclines

• Respiratory infections  Community-acquired pneumonia (doxy)  Acute exacerbation of chronic bronchitis  Pertussis • STDs –Chlamydia, Syphilis, gonorrhea • Treatment or prophylaxis of malaria • The Others:  Rocky Mountain Spotted Fever, Q Fever, Lyme  Brucellosis, Bartonellosis, plague, Tularemia, chancroid, anthrax, H. pylori

cdc.gov; en.wikipedia.org;

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The Clinical Uses of Tetracyclines/Glycylcyclines

• Polymicrobial infections (Tigecycline)  Complicated skin and soft tissue infections  Intraabdominal infections

• Acne

• SIADH (demeclocycline)

Tetracycline/Tigecycline Adverse Effects • Gastrointestinal  Nausea, vomiting – high incidence with tigecycline (29%)  Diarrhea, pseudomembranous colitis

• Hypersensitivity  Rash, pruritus, urticaria, angioedema, anaphylaxis

• Photosensitivity  Exaggerated sunburn

Tetracycline

Tabletsmanual.com;

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photosensitivity

Reference.medscape.com; forhealty.com

Tetracycline/Tigecycline Adverse Effects • Renal  Fanconi-like syndrome with outdated tetracycline  Reversible dose-related diabetes insipidus (demeclocycline)

• Other  Hepatic enzyme elevation

• Pregnancy Category D  Discoloration of permanent teeth and decreased bone growth in children

Tetracycline

Emdental.com;

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Sulfonamides and Trimethoprim

Sulfonamides

• The first effective antibiotics used to prevent and treat infections

• Led to a dramatic reduction in morbidity/ mortality associated with treatable infections

• Inhibits dihydropteroate synthetase – • Inhibits incorporation of p-aminobenzoic acid (PABA) into tetrahydropteroic acid

• Bacteriostatic

Sulfonamides

• Short- or Medium-Acting  Sulfisoxazole  Sulfamethoxazole  Sulfadiazine  Sulfamethizole • Long-Acting  Sulfadoxine . Combined with pyrimethamine (Fansidar)

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Trimethoprim

• 2,4-diamino-pyrimidine developed in the 1950s • Bacteriostatic • Inhibits dihydrofolate reductase  Interferes with conversion of dihydrofolate to tetrahydrofolate

Trimethoprim-Sulfamethoxazole (TMP-SMX, Bactrim)

In the 1970s, TMP was combined with sulfonamides

Bactericidal in combination Trimethoprim with synergistic activity (TMP) + Broader spectrum of activity

Decreased emergence of resistance Sulfamethoxazole (SMX)

PABA

Dihydropteroate Synthetase Sulfamethoxazole Dihydrofolic Acid

Dihydrofolate Reductase Trimethoprim

Tetrahydrofolic Acid

Purines

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TMP-SMX Mechanisms of resistance • Sulfonamides  Resistance widespread . Streptococci, Staphylococci, Enterobacteriacae, Neisseria sp., Pseudomonas sp., Shigella, Salmonella  PABA overproduction  Structural change of Dihydropteroate synthetase  Plasmid mediated production of drug resistant DHPS or decreased bacterial cell wall permeability to sulfonamides

TMP-SMX Mechanisms of resistance • Trimethoprim  Chromosomal or plasmid mediated  Plasmid-mediated production of dihydrofolate reductase resistant to trimethoprim  Changes in cell permeability

TMP-SMX Spectrum of Activity

Gram-Positive Gram-Negative Staph aureus (incl some Acinetobacter MRSA, CA-MRSA) Enterobacter S. pyogenes E. coli Nocardia K. pneumoniae Listeria monocytogenes Proteus Anaerobes Salmonella, Shigella No Activity Haemophilus spp. Other N. gonorrhoeae Stenotrophomonas maltophilia Pneumocystis carinii

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TMP-SMX Pharmacology

• Absorption – available IV and PO  Rapidly and completely absorbed (F > 90%)  Peaks are higher and more predictable with IV administration

• Distribution  Good distribution – lungs, urine, prostate, etc  Penetrates the CSF – TMP (30-50%), SMX (20%)  SMX is 70% protein bound

TMP-SMX Pharmacology

Elimination  Both are eliminated by the liver and kidney  TMP – 60% excreted unchanged in the urine over 24 hours  SMX – 25 to 50% excreted unchanged in the urine over 24 hours  Half-life . TMP = 11 hours . SMX = 9 hours  Dose adjustment required in patients with a CrCl < 30 ml/min

TMP-SMX Clinical Uses

• Acute, chronic, or recurrent infections of the urinary tract

• Acute or chronic bacterial prostatitis

• Skin infections due to CA-MRSA

• Bacterial Sinusitis

• Nocardia

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TMP-SMX Clinical Uses

• Pneumocystis carinii pneumonia

• Stenotrophomonas

• Toxoplasmosis

• Listeria monocytogenes

• Nocardia

TMP-SMX Adverse Effects • Gastrointestinal  Nausea, vomiting, diarrhea, glossitis  Jaundice  Hepatic necrosis

• Hematologic  Leukopenia, thrombocytopenia, eosinophilia  Acute hemolytic anemia, aplastic anemia, agranulocytosis  Megaloblastic anemia (impaired folate usage with prolonged administration)

TMP-SMX Adverse Effects • Hypersensitivity  Rash, urticaria, epidermal necrolysis, Stevens- Johnson, drug fever • CNS  Headache, aseptic meningitis, seizures • Renal toxicity  Tubular necrosis  Interstitial nephritis • Drug-induced lupus • Serum sickness-like syndrome • Other - crystalluria

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TMP-SMX Drug Interaction

Drug Interaction Phenytoin  phenytoin levels Warfarin  Anticoagulant effect Methotrexate decrease renal clearance

TMP-SMX Dosing • Oral tablets  Single Strength (SS) = 80mg TMP and 400mg SMX  Double Strength (DS) = 160mg TMP and 800mg SMX • Oral Suspension  40mg TMP and 200mg SMX per 5 ml • Intravenous Solution  16mg TMP and 80mg SMX per ml

TMP-SMX Dosing

Indication Adult Dose

Urinary tract infections One DS tablet twice daily

Prostatitis One DS tablet twice daily

GI Infections One DS tablet twice daily

CA-MRSA Skin Infections Two DS tablets twice daily

Pneumocystis carinii Treatment: 15 to 20 mg/kg TMP daily pneumonia divided every 8 hours (PO or IV) Prophylaxis: one DS tablet daily

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Chloramphenicol

Chloramphenicol Background

• Isolated from mulched field and compost • Streptomyces venezuelae • Introduced into use in U.S. in 1949 • Due to significant adverse events, this agent is not used in the U.S. • Use is common in the developing world

Chlorampenicol Mechanism of action

• Binds to 50s subunit of 70s ribosome • Prevents peptide bond formation • Static activity except for:  Haemophilus influenza  Streptococcus pneumoniae  Neisseria meningitidis

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Accessmedicine.ca;

Chloramphenicol Resistance mechanism(s) • Reduced permeability or uptake • Ribosomal mutation • Acetyltransferase inactivation  Responsible for widespread outbreaks of typhoid fever and Shigella dysentery in Central and South America, Vietnam, India

Chloramphenicol Pharmacology

• Absorption  Well absorbed by the GI tract  IV administration – peak level approximately 70% of peak following oral administration

• Distribution  Lipid soluble  Not highly protein bound (25-50%)  CSF levels 30-50% of serum levels

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Chloramphenicol Pharmacology

• Elimination  Metabolized by the liver  Enterohepatic circulation  Excreted by the kidneys • Decrease dose in liver failure • Does adjustment not required in renal failure

Chloramphenicol Antimcrobial spectrum

•Bacteria  Gram Positives . Unreliable against Staph aureus and not active against enterococci  Gram Negatives . Not active against P. aeruginosa  Anaerobes (Gram negative and Gram positive)

Chloramphenicol Antimicrobial spectrum

• Rickettsiae sp. • Spirochetes • Chlamydia • Mycoplasma

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Chloramphenicol Clinical uses • None in U.S.

• Third and Developing World  Pneumonia  Bacterial meningitis  Typhoid fever

• Rocky mountain spotted fever

Chloramphenicol Adverse Effects

• Hematologic  Reversible bone marrow suppression  Aplastic anemia (1 in 24,500 – 40,800) • Gray baby syndrome (neonates)  Abdominal distention  Vomiting  Flaccidity  Cyanosis  Circulatory collapse/Death

Pathwiki.pbworks.com; drugline.org;

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Chloramphenicol Adverse Effects

• Optic neuritis • Hypersensitivity reaction • Anaphylaxis • GI intolerance (vomiting, diarrhea) • Stomatitis • porphyria

Urinary Tract Agents

• Nitrofurantoin • Methenamine

UTI Agents Mechanism of Action

• Nitrofurantoin • Methenamine  Poorly understood  Converted in acid pH  Binds to ribosomal to ammonia and proteins formaldehyde  Inhibits translation  Formaldehyde – non- specific denaturant of  Inhibits bacterial respiration and proteins and nucleic pyruvate metabolism acids

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UTI Agents Mechanism of Resistance

• Nitrofurantoin • Methenamine  Poorly understood  Alkaline urine  Development of  No bacterial resistance resistance while on to formaldehyde treatment rare described  E. coli – Chromosomal or plasmid-mediated production of nitrofuran reductase

UTI Agents Pharmacology: absorption

• Nitrofurantoin • Methenamine  40-50% absorption  Rapid absorption after following oral oral administration administration  May be partially  Occurs in small degraded by gastric intestine acid  Enhanced with food

UTI Agents Pharmacology: distribution

• Nitrofurantoin • Methenamine  Large urine  Rapid absorption concentrations following oral dose  Low/undetectable  Broad distribution serum in tissue concentration  Therapeutic concentrations not attained in prostate

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UTI Agents Pharmacology: excretion

• Nitrofurantoin • Methenamine  Eliminated in the  Renal excretion urine  Half-life 3-4 hours . Glomerular filtration with normal renal . Tubular secretion function . Tubular reabsorption  Biliary excretion: minor  Serum half life <30 minutes

UTI Agents Clinical uses

• Nitrofurantoin • Methenamine  Acute,  Suppression or uncomplicated prophylaxis against UTIs recurrent UTIs

 Do not use for:  Do not use for: . Pyelonephritis . Established . Complicated UTi infections . Prophylaxis against catheter-associated UTI

UTI Agents - Nitrofurantoin Spectrum of activity

• Active against • Not active against  E. coli  Pseudomonas  Citrobacter, sp. aeruginosa  Group B  Proteus Streptococcus  Providencia  Staphylococcus  Morganella saprophyticus  Serratia  Enterococcus  Acinetobacter (including some strains of VRE)

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UTI Agents - Methenamine Spectrum of activity

• Methenamine has no antimicrobial activity

• Formaldehyde resistance not described and has broad antimicrobial activity

• May not be effective against urease producing organisms (Proteus)

UTI Agents - Nitrofurantoin Adverse reactions

• GI intolerance • Rashes • Acute pulmonary symptoms – reversible hypersensitivity phenomenon  Weeks to months after drug exposure  Rapid onset of fever, cough, dyspnea, myalgia  Peripheral blood eosinophilia and lower lobe pulmonary infiltrates

UTI Agents - Nitrofurantoin Adverse reactions

• Subacute and chronic pulmonary reaction  Gradual onset of progressive, non-productive cough and dyspnea  Interstitial infiltrate on CXR  Reversible but may lead to pulmonary fibrosis  May have + antinuclear antibodies  Bronchiolitis obliterans and organizing pneumonia reported

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UTI Agents - Methenamine Adverse reactions

• Generally well-tolerated • GI (nausea, vomiting) •Rash • Pruritis • Bladder irritation • Hemorrhagic cystitis (higher doses)

UTI Agents - Methenamine Adverse reactions

• Peripheral sensory neuropathy • Hepatitis • Hemolytic anemia • Leukopenia • Aplastic anemia • Megaloblastic anemia (folic acid responsive) • Eosinophilia

Urinary Tract Agents Dosing • Nitrofurantoin • Methenamine  Uncomplicated  >12 years old: 1g cystitis: 50-100 mg twice daily to 4 orally q6 hours for times daily max 7 days  6-12 y/o: 500mg to  Prophylaxis: 50- 1g twice daily 100 mg by mouth daily

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Questions??

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Protein –synthesis inhibitors

Macrolides Ketolides Streptogramins Lincosamides

Macrolide Lecture Objectives

Identify the differences between the macrolides and ketolides with respect to:  Mechanism of Action  Mechanisms of Resistance  Spectrum of Activity  Pharmacology  Clinical Uses  Major Adverse Effects  Drug Interactions

Major mechanism of resistance to antimicrobials

• Enzymatic inactivation • Target site absent: intrinsic resistance • Target site modification • Excessive binding sites • Altered cell wall permeability • Drug efflux

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Macrolides • Macrolides in clinical use today include erythromycin, clarithromycin, and azithromycin • Erythromycin is a naturally-occurring macrolide derived from Streptomyces erythreus that has a relatively narrow spectrum; and is acid labile, poorly tolerated after PO administration, and has a short elimination half-life • Structural derivatives include clarithromycin and azithromycin:  Broader spectrum of activity  Improved PK properties – better bioavailability, better tissue penetration, prolonged half-lives  Improved tolerability  Fidaxomicin: non absorbed macrolide for C. difficile colitis

Macrolide Structure

Fidoxamicin

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Macrolides Mechanism of Action  Inhibit protein synthesis by reversibly binding to the 50S ribosomal subunit . Induce dissociation of peptidyl RNA from the ribosome during the elongation phase  Macrolides typically display bacteriostatic activity, but may be bactericidal when present at high concentrations against very susceptible organisms  Erythro and clarithro display time-dependent activity; azithro is concentration-dependent

Macrolides Mechanisms of Resistance  Active efflux (accounts for 70-80% in US) – mef gene encodes for an efflux pump that pumps the macrolide out of the cell away from the ribosome; confers low level resistance to macrolides  Altered target sites (primary resistance mechanism in Europe) – encoded by the erm gene which alters the macrolide binding site on the ribosome; confers high level resistance to all macrolides, clindamycin, and Synercid®  Cross-resistance occurs between all macrolides

Macrolide Spectrum of Activity

Gram-Positive Aerobes – erythromycin and clarithromycin display the best activity (Clarithro>Erythro>Azithro) . Methicillin-susceptible Staphylococcus aureus (MSSA)* . Streptococcus pneumoniae (only PSSP) – resistance is developing . Group and viridans streptococci . Bacillus spp., Corynebacterium spp.

* = target organism

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Macrolide Spectrum of Activity

Gram-Negative Aerobes – newer macrolides with enhanced activity

(Azithro>Clarithro>Erythro)

• H. influenzae (not erythro), M. catarrhalis, Neisseria spp. • Do NOT have activity against any Enterobacteriaceae

Macrolide Spectrum of Activity Anaerobes – activity against upper airway anaerobes Atypical Bacteria – all macrolides have excellent activity against atypical bacteria including: . Legionella pneumophila – DOC* . Chlamydophila (psittacosis) and Chlamydia spp. . Mycoplasma spp. . Ureaplasma urealyticum Other Bacteria – Mycobacterium avium complex (MAC – only A and C), M. chelonae, M. marinum, Treponema pallidum, Campylobacter, H.pylori combination tx, Borrelia, Bordetella, Brucella, Pasteurella * = target organism

Macrolides Pharmacology

Absorption  Erythromycin – variable absorption (F = 15 to 45%); food may decrease the absorption . Base: destroyed by gastric acid; enteric coated . Esters and ester salts: more acid stable  Clarithromycin – acid stable and well- absorbed (F = 55%) regardless of presence of food  Azithromycin –acid stable; F = 37% regardless of presence of food

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Macrolides Pharmacology Distribution  Extensive tissue and cellular distribution – clarithromycin and azithromycin with extensive Vd’s  Minimal CSF penetration Elimination  Erythromycin is excreted in bile and metabolized (cyp450)  Clarithromycin is metabolized and also partially eliminated by the kidney (18% of parent and all metabolites); requires dose adjustment when CrCl < 30 ml/min  Azithromycin eliminated by biliary excretion  Variable elimination half-lives (1.4 hours for erythro; 3 to 7 hours for clarithro; 68 hours for azithro)  NONE of the macrolides are removed during hemodialysis!

Macrolides Clinical Uses • Respiratory Tract Infections  Pharyngitis/ Tonsillitis – pen-allergic patients  Sinusitis,COPD exaccerbation, Otitis Media (azithro best if H. influenzae suspected)  Community-acquired pneumonia – monotherapy in outpatients; with ceftriaxone for inpatients  With ceftriaxone for CABP for “anti- inflammatory effect”(J Antimicrob Chemother. 2005 Jan;55(1):10-21. Epub 2004 Dec 8).

Macrolides Clinical Uses (contd.) • Uncomplicated Skin Infections • STDs – Single 1 gram dose of azithro • MAC – Azithro for proph; Clarithro/ Azithro for RX

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Macrolides Clinical Uses

Alternative for Penicillin-Allergic Patients:  Group A Strep URIs  Prophylaxis of bacterial endocarditis  Syphilis and GC  Rheumatic fever prophylaxis  Currently, Strep.sp. and S. pneumoniae increasingly resistant to macrolides – so far not a problem for telithromycin (not marketed)

Macrolides Adverse Effects • Gastrointestinal – up to 33%  Nausea, vomiting, diarrhea, dyspepsia  Most common with erythro; less with new agents • Cholestatic hepatitis - rare  > 1 to 2 weeks of erythromycin estolate • Thrombophlebitis – IV Erythro and Azithro  Dilution of dose; slow administration • Allergic reactions.

Macrolides Adverse Effects • Prolonged QTc; aggravated by concomitant drugs that also prolong QTc (e.g. anti‐arrhythmics) • Exacerbation of myasthenia gravis (telithro/azithro) • Transient /reversible tinnitus or deafness •Drug‐drug: e.g., Colchicine: potentially fatal interaction.

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Macrolides Drug Interactions Erythromycin and Clarithromycin ONLY– are inhibitors of cytochrome p450 system in the liver and may increase concentrations of: Theophylline Digoxin, Disopyramide Carbamazepine Valproic acid Cyclosporine Terfenadine, Astemizole Phenytoin Cisapride Warfarin Ergot alkaloids NOT AZITHROMYCIN!!!

Macrolides versus Ketolides

C11-C12 Carbamate:  potency, overcomes O macrolide resistance O R Methoxy group: O  acid stability HO N HO OR OCH 11 O 11 3 12 6 12 6

O O Sugar O O Sugar

3 3 O Cladinose O O

Keto Group: Macrolides Ketolides  acid stability, overcomes macrolide resistance

Ketolides

• One agent approved = Telithromycin - Ketek® • Mechanism of action: inhibit protein synthesis  Bind to two domains (II & V) on the 50S ribosomal subunit; binds 10 times more strongly to domain II than the macrolides  May account for enhanced antimicrobial activity as well as superior activity against bacteria with erm- mediated (MLSB) resistance • Bacteriostatic • Resistance has been noted – ribosomal binding site alterations • In vitro activity against macrolide-resistant Streptococcus and Staphylococcus; poor activity against H. influenzae

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Telithromycin - Ketek • Pharmacology – PO only  Absorption: F = 57%, unaffected by food  Distribution: excellent into tissues and cells; protein binding = 60 to 70%  Elimination: metabolized by cytochrome p450 (3A4); half-life = 10 hours  No dose adjustment in renal insufficiency • Adverse effects – use has been limited  Gastrointestinal – diarrhea, hepatotoxicity  QTc prolongation  Decreased visual acuity, blurred vision

Telithromycin - Ketek

• Drug Interactions  Inhibitor of Cytochrome p450 3A4 – similar drug interactions as erythro and clarithro (digoxin, phenytoin, warfarin, cyclosporine) • Clinical Uses  Community-acquired pneumonia  Acute bacterial sinusitis  Acute exacerbations of chronic bronchitis

Streptogramins

• Synercid® is the first available streptogramin, which received FDA approval in September 1999 • Developed in response to the need for antibiotics with activity against resistant gram-positive bacteria, namely VRE • Synercid® is a combination of two semi- synthetic pristinamycin derivatives in a 30:70 w/w ratio: Quinupristin:Dalfopristin

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Synercid® Structure

Synercid®

Mechanism of Action • Each agent acts individually on 50S ribosomal subunits to inhibit early and late stages of protein synthesis • Binds on the 50S ribosome near where the macrolides and clindamycin bind • Bacteriostatic (may be bactericidal against some bacteria) Mechanisms of Resistance • Alterations in ribosomal binding sites (erm) • Enzymatic inactivation

Synercid® Spectrum of Activity

Gram-Positive Bacteria  Methicillin-Susceptible and Methicillin-Resistant Staph aureus and coagulase-negative staphylococci*  Streptococcus pneumoniae (including PRSP*), viridans streptococcus, Group streptococcus  Enterococcus faecium (including VRE)*  Corynebacterium, Bacillus. Listeria, Actinomyces  Clostridium spp. (except C. difficile), Peptococcus, Peptostreptococcus Gram-Negative Aerobes (not used here)  Limited activity against Neisseria sp. and Moraxella Atypical Bacteria (not used here)

 Mycoplasma, Legionella * = target organisms

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Synercid® Pharmacology

• Time-dependent bactericidal activity • PAE exists for Gram-Positive Bacteria  2 to 8 hours for S. aureus  8.5 hours for VSE; 0.2 to 3.2 hours for VRE • Absorption – only available parenterally • Distribution – penetrates into extravascular tissue, lung, skin/soft tissue; minimal CSF penetration • Elimination – both agents are metabolized; t½ is 0.6- 1 hour for quinu and 0.3 hours for dalfo

Synercid® Clinical Uses and Dosing

• Very expensive - ~ $350 per day • VRE (faecium) bacteremia (7.5 mg/kg Q8h) – 3rd line • Complicated skin and soft tissue infections due to MSSA or Streptococcus pyogenes (7.5 mg/kg Q12h) • Limited data in treatment of catheter- related bacteremia, infections due to MRSA, and community-acquired pneumonia (5 to 7.5 mg/kg Q8h)

Synercid® Drug Interactions

Cytochrome p450 3A4 Inhibitor

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Synercid® Adverse Effects

• Venous irritation – especially when administered through a peripheral vein • Gastrointestinal – nausea, vomiting, diarrhea • Myalgias, arthralgias – 2% •Rash

Clindamycin

Clindamycin is a semisynthetic derivative of lincomycin, isolated from Streptomyces lincolnesis in 1962. Clindamycin is absorbed better than other lincosamides and has a broader spectrum of activity.

Clindamycin

Mechanism of Action  Inhibits protein synthesis by binding exclusively to the 50S ribosomal subunit . Binds in close proximity to macrolides and Synercid– may cause competitive inhibition  Clindamycin typically displays bacteriostatic activity, but may be bactericidal when present at high concentrations against very susceptible organisms

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Clindamycin Mechanisms of Resistance  Altered target sites – encoded by the erm gene, which alters 50S ribosomal binding site; confers high level resistance to macrolides, clindamycin and Synercid (MLSb resistance)  Active efflux – mef gene encodes for an efflux pump that pumps macrolides out of the cell but NOT clindamycin; confers low level resistance to macrolides, but clindamycin still remains active

Clindamycin Spectrum of Activity

Gram-Positive Aerobes

Methicillin-susceptible Staphylococcus aureus* , and some CA-MRSA Streptococcus pneumoniae (only PSSP) – resistance is developing Group and viridans streptococci

* = target organism

Clindamycin Spectrum of Activity

Anaerobes – best activity against Above the Diaphragm Anaerobes (ADA)

Peptostreptococcus some Bacteroides spp* Actinomyces Prevotella spp. Propionibacterium Fusobacterium Clostridium spp. (not C. difficile)

Other Bacteria – Pneumocystis carinii, Toxoplasmosis gondii, Malaria * = target organism

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Clindamycin Pharmacology Absorption – available IV and PO  Rapidly and completely absorbed (F = 90%); food with minimal effect on absorption Distribution  Good serum concentrations with PO or IV  Good tissue penetration including bone; minimal CSF penetration Elimination  Clindamycin primarily metabolized by the liver (85%); enterohepatic cycling  Half-life is 2.5 to 3 hours  Clindamycin is NOT removed during hemodialysis

Clindamycin Clinical Uses

• Anaerobic Infections OUTSIDE of the CNS  Pulmonary, intraabdominal, pelvic, diabetic foot and decubitus ulcer infections • Skin & Soft Tissue Infections  Pen-allergic patients  Patients with infections due to CA-MRSA • Other  Alternative for C. perfringens, PCP, Toxoplasmosis, malaria, bacterial vaginosis

Clindamycin Adverse Effects • Gastrointestinal – 3 to 4% (esp with PO)  Nausea, vomiting, diarrhea, dyspepsia • Clostridium difficile colitis – one of worst inducers  Mild to severe diarrhea  Requires treatment with metronidazole or oral vancomycin • Hepatotoxicity - rare  Elevated transaminases • Allergy - rare

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Thank you!!

14 Pharmacology and Therapeutics Aminoglycosides October 30, 2012 Constance Pachucki, M.D.

#34 – AMINOGLYCOSIDES Drugs covered Amikacin, tobramycin, gentamycin, streptomycin

I. INTRODUCTION

The first group of antibiotics that are dosed individually for each patient and require serum concentration monitoring

II. MECHANISM OF ACTION

A. The mechanism of action of the aminoglycosides is multifactorial, but ultimately involves the inhibition of protein synthesis

B. Aminoglycosides irreversibly bind to the 30S ribosomal subunit (some to 50S subunits), which results in a disruption in the initiation of protein synthesis, a measurable decrease in protein synthesis, and misreading of messenger RNA.

1. The aminoglycosides must first bind to cell surface, not energy dependent

2. Transported across the bacterial cytoplasmic membrane by two energy dependent mechanism.

3. Ribosomal binding inhibits the synthesis of proteins, which disrupts the structure of the cytoplasmic membrane.

4. Aminoglycosides require aerobic energy to enter the cell and bind to ribosomes. (They are inactive against anaerobic bacteria)

C. Aminoglycoside antibiotics are rapidly bactericidal in a concentration- dependent manner, except against Enterococcus spp.

D. Post-antibiotic effect (PAE) 1. Suppression of bacterial growth after concentrations have fallen below MIC

2. Finite duration - 2 to 4 hours

3. Can dose every 24 hours

1 Pharmacology and Therapeutics Aminoglycosides October 30, 2012 Constance Pachucki, M.D.

III. MECHANISMS OF RESISTANCE

A. Alteration in aminoglycoside uptake

1. Chromosomal mutations that influence any part of the binding and/or electrochemical gradient that facilitates aminoglycoside uptake – leads to decreased penetration of aminoglycoside inside the bacteria.

B. Synthesis of aminoglycoside-modifying enzymes

1. Plasmid-mediated resistance factor that enables the resistant bacteria (usually gram-negative) to enzymatically modify the aminoglycoside by acetylation, phosphorylation, or adenylation. The modified aminoglycoside displays poor uptake and binds poorly to ribosomes, leading to high-level resistance.

2. A large number of enzymes have been identified, and cross-resistance may occur. Gentamicin and tobramycin are generally susceptible to the same modifying enzymes, while amikacin is resistant to many enzymes.

C. Alteration in ribosomal binding sites

1. Ribosomal binding site alterations rarely occur as a mechanism of resistance to gentamicin, tobramycin, and amikacin.

IV. SPECTRUM OF ACTIVITY

A. Gram-negative aerobes

1. Enterics E. coli, K. pneumoniae, Proteus spp. Acinetobacter, Citrobacter, Enterobacter spp. Morganella, Providencia, Serratia, Salmonella, Shigella)

2. Pseudomonas aeruginosa

B. Mycobacteria

1. Tuberculosis – streptomycin

2. Non-tuberculous mycobacteria - streptomycin or amikacin

C. Not active against anaerobes

2 Pharmacology and Therapeutics Aminoglycosides October 30, 2012 Constance Pachucki, M.D.

D. Gram-positive aerobes: (NEVER USED ALONE, are used with cell-wall active agents to provide synergy; LOW DOSES) – primarily gentamicin

Most strains of S. aureus and coagulase-negative staphylococci Viridans streptococci Enterococcus spp. (gentamicin or streptomycin)

E. Synergy

1. Synergy exists between the aminoglycosides and cell-wall active agents, such as -lactams and vancomycin. Synergy is demonstrated when the effect of the drugs in combination is greater than the anticipated results based on the effect of each individual drug; the effects are more than additive.

2. Possibly due to enhanced uptake of aminoglycoside into bacteria whose cell walls have been damaged by cell wall synthesis inhibitors.

3. Synergy has been demonstrated for:

Enterococcus - with ampicillin, penicillin or vancomycin (gent or strep) S. aureus, viridans streptococci- with -lactams or vancomycin (gent) P. aeruginosa and other gram-negative aerobes - with -lactams (gent- amicin, tobramycin or amikacin)

V. PHARMACOLOGY

A. Absorption 1. Aminoglycosides are very poorly absorbed from the gastrointestinal tract.

2. Aminoglycosides are well absorbed after IM administration, Rarely used.

3. Intermittent intravenous infusion is the preferred route of administration, B. Elimination

1. 85 to 95% of an administered aminoglycoside dose is eliminated unchanged by the kidney via glomerular filtration, resulting in high urinary concentrations.

VII. CLINICAL USES

A. Largely replaced by Beta-lactam antibiotic

3 Pharmacology and Therapeutics Aminoglycosides October 30, 2012 Constance Pachucki, M.D.

B. Aminoglycosides are toxic and require monitoring of serum levels

C. RARELY USED AS MONOTHERAPY

1. Used in combination with beta-lactam to treat pseudomonas aeruginosa and other highly resistant gram negative bacilli

D. Urinary tract infections, sepsis especially urinary source or intra-abdominal source, skin and soft tissue infections,

1. Does not penetrate into lung, so cannot be used alone for pneumonia

E. Amikacin

1. Used for gram negative infections with multi-drug resistance

2 Least likely to be inactivated by bacterial resistance enzymes

F. Gentamicin or streptomycin

1. used for synergy with appropriate cell wall active agents (ampicillin, vancomycin, etc) for the treatment of serious infections (endocarditis) due to enterococci, viridans streptococci, or staphylococci.

G. Streptomycin is used in conjunction with other antituberculous medications

VIII. ADVERSE EFFECTS

A. Nephrotoxicity

1. Manifested as nonoliguric azotemia secondary to proximal tubular damage, leading to an increase in BUN and serum creatinine.

2. Reversible if the aminoglycoside dose is adjusted or the drug is discontinued early enough.

3. The risk factors for the development of nephrotoxicity include prolonged high trough concentrations, prolonged therapy > 2 weeks, the presence of underlying renal insufficiency, advanced age, hypovolemia, and the use of concomitant nephrotoxins (vancomycin, amphotericin B, cisplatin, CT contrast, etc.).

4. Comparative nephrotoxicity-gentamicin most nephrotoxic

4 Pharmacology and Therapeutics Aminoglycosides October 30, 2012 Constance Pachucki, M.D.

a. Gent>tobra>amikacin>streptomycin

B. Ototoxicity - auditory and vestibular

1. Due to eighth cranial nerve damage.

a. Damage is irreversible, and must be caught early.

b. Vestibular symptoms include dizziness, nystagmus, vertigo and ataxia

c. Auditory toxicity tinnitus, hearing loss

2. Auditory toxicity is more common with amikacin>gentamicin and tobramycin

3. Vestibular toxicity is more common with streptomycin>gentamicin, or tobramycin>amikacin.

4. The risk factors for the development of ototoxicity include prolonged high trough concentrations, prolonged therapy > 2 weeks, the presence of renal insufficiency, advanced age, and the concomitant use of other ototoxic drugs(vancomycin, loop diuretics).

C. Other rare adverse effects of the aminoglycosides include neuromuscular blockade

5 Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin November 1, 2012 and Oral Anticoagulants D. Moorman., Ph.D. TREATMENT OF THROMBOSIS: Heparin, Low Molecular Weight Heparin and Oral Anticoagulants

I. ANTICOAGULANT DRUGS . A. Introduction. Drugs used to anticoagulate blood for the treatment of thrombosis and for surgical indications.

B. Heparin: 1. Naturally occurring anticoagulant found in the granules of mast cells along with histamine and serotonin. 2. Chemistry: Heparin is a strongly acidic (highly ionized) mucopolysaccharide composed of repeating units of sulfated glucuronic acid and sulfated glucosamine.

MOLECULAR HETEROGENEITY IN HEPARIN (Heparin is composed of high molecular weight and low molecular weight components)

From: Fareed et al, 1989. Chemical and Biological Heterogeneity in Low Molecular Weight Heparins: Implications for Clinical Use and Standardization. Seminars in Hemostasis Thrombosis, 15(4): 440-463.

a. Heparin's composition varies in molecular weight constituents (2,000 - 40,000 DA)

1 Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin November 1, 2012 and Oral Anticoagulants D. Moorman., Ph.D.

Heparin is composed of sulfated polysaccharide chains which vary in length (15-50 hexose units). These chains also exhibit different behaviors and interact with blood vessels and cells.

CHEMICAL STRUCTURE OF A HEPARIN OLIGOSACCHARIDE UNIT

Refer to Figure 34-4 in Katzung, 10th Edition, pg. 547.

3. Source:

a. Extracted from tissues rich in mast cells (beef lung and porcine intestine).

4. Biological standardization:

a. Because of variability in its molecular composition heparin is assayed and compared to a USP reference standard in pooled citrated sheep plasma to which Ca+2 has been added. b. 1 mg of heparin should be equivalent to at least 120 USP units (10 g = 1 unit).

5. Actions of heparin:

a. Inhibits the action of activated factor Xa and factor IIa (Thrombin). b. Inhibits the action of several other serine protease enzymes (XIIa, XIa). c. Inhibits the aggregation of platelets (at high concentration). d. Plasma clearing effect: turbid plasma is rapidly cleared of fat chylomicrons by a release of lipase from the blood vessels. e. Binds to vascular lining and neutralizes the positive charge. f. Causes a release of tissue factor pathway inhibitor (TFPI).

6. Heparin preparations:

a. Mucosal heparin - sheep (rarely used) - porcine (derived from pig intestine) b. Lung heparin

2 Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

- Mostly bovine preparations, used in cardiac surgery

c. Different salts of heparin (Na+, Ca+2 ) d. Low molecular weight heparins -Enoxaparin®, Fragmin®, Ardeparin® and Tinzaparin® e. Synthetic heparin (Heparin pentasaccharide) Arixtra®

7. Route of administration and therapeutic monitoring:

a. Intravenous and Subcutaneous b. Not absorbed via oral or rectal route. Heparin is highly charged at all pH's. Special formulations of heparin are developed for oral use. c. There is a poor correlation between the dose of heparin and weight of the patient. The anticoagulant effect is carefully monitored using the APTT method to determine the dose.

8. Metabolism:

a. 20-25% of heparin is excreted in urine b. Some heparin is picked up by mast cells c. Endothelium is able to bind heparin d. Metabolized in liver by heparinase into small components

9. Duration of action:

a. Biologic T½ of intravenous heparin is l-3 hours, depending on the dose. Onset of action is 5-10 minutes (as measured by APTT method).

10. Endogenous modulators of heparin action:

a. AT (main heparin co-factor) b. Heparin cofactor II (second cofactor) c. Tissue factor pathway inhibitor (TFPI) d. Platelet factor 4 (heparin neutralizing protein)

11. Side effects of heparin:

a. Hemorrhagic complications Adrenal, gut, etc. b. Heparin induced thrombocytopenia and heparin induced thrombosis - Generation of antiheparin platelet factor 4 antibodies. These antibodies activate platelets and endothelial cells. c. Osteoporotic manifestation with spontaneous fracture following chronic administration and large doses

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

d. Alopecia (loss of hair) Long-term usage

12. Clinical use of heparin:

a. Therapeutic anticoagulation b. Surgical anticoagulation c. Prophylactic anticoagulation d. Unstable angina and related coronary syndromes e. Adjunct therapy with thrombolytic drugs f. Thrombotic and ischemic stroke

13. Protamine sulfate and heparin neutralization:

a. Protamine is a powerful heparin antagonist. It has a low molecular weight and is a highly basic protein found in the sperm of certain fish. b. It combines with strongly acidic heparin to form a stable salt with loss of anticoagulant activity. c. Available as a 1% solution and generally used on a weight basis. d. One USP unit of heparin is neutralized by 10 g of protamine (2500 units of heparin is neutralized by 25 mg of protamine).

e. Intravenous injection of protamine may cause the following:

Fall in blood pressure

Bradycardia

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

II. LOW MOLECULAR WEIGHT HEPARINS & SYNTHETIC HEPARIN PENTASACCHARIDE

1.

From: Fareed et al, 1989. Chemical and Biological Heterogeneity in Low Molecular Weight Heparins: Implications for Clinical Use and Standardization. Seminars in Hemostasis Thrombosis, 15(4): 440-463.

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

Structure of Chemically Synthesized Heparin Pentasaccharides

Heteogeneity in Low Molecular Weight Heparins: Implications for Clinical Use and Standardization. Seminarrs in Hemostasis Thrombosis, 15(4):440-463, 1993

2. Bioavailability of low molecular weight heparins in % bioavailability after subcutaneous administration. - Low molecular weight heparins are bioavailable at 100% whereas heparin has a limited bioavailability (<30%)

From: Fareed et al, 1989. Chemical and Biological Heterogeneity in Low Molecular Weight Heparins: Implications for Clinical Use and Standardization. Seminars in Hemostasis Thrombosis, 15(4): 440-463.

3. Clinical advantages of low molecular weight heparins:

a. Better bioavailability b. Longer duration of action c. Less bleeding d. Lesser thrombocytopenia

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

4. Clinical use:

a. Prophylaxis of DVT b. Treatment of DVT c. Management of acute coronary syndromes d. Other uses such as anticoagulation for surgical and interventional cardiovascular procedures

III. GENERIC ENOXAPARIN

1. Sandoz Enoxaparin 2. Amphastar Enoxaparin

IV. ANTITHROMBIN – CONCENTRATES (AT):

1. Antithrombin-concentrate is prepared by using heparin-sepharose affinity chromatography. This concentrate is used to treat patients with acquired or congenital antithrombin- deficiency. AT is also useful in sepsis and disseminated intravascular coagulation. 2. Available as a plasma-derived concentrate in batches of 500 units 3. Can be used for patients with hypercoagulable states

V. DIRECT ANTITHROMBIN AGENTS:

Hirudin is a protein from the saliva of the medicinal leech (Hirudo medicinalis) which contains several pharmacologically active substances. Using recombinant technology recombinant forms of this drug are produced. Currently r-hirudin is used in the anticoagulant management of heparin induced thrombocytopenic patients. A commercial preparation, namely, refludan (Pharmion) is available for clinical use.

Argatroban is a synthetic antithrombin agent which is currently used as an anticoagulant in patients who can not be treated with heparin, special usage in the management of heparin induced thrombocytopenia.

Bivalirudin (Angiomax®) is a synthetic antithrombin agent. This agent is a hybrid molecule between a component of hirudin and a tripeptide. This drug is approved for PTCA anticoagulation.

PROPHYLAXIS AND TREATMENT OF THROMBOSIS: ORAL ANTICOAGULANTS

I. Warfarin and the coumarin anticoagulants:

1. Only the coumarin derivatives are used in the U.S. The warfarin, (Coumadin®), brand of oral anticoagulant is most widely prescribed.

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

2. Prophylactic use: Prevention of thrombotic disorders 3. Therapeutic use: Treatment of established thrombus

Integrated Coagulation Cascade and Its Modulation by Anticoagulant Drugs.

Refer to Katzung 10th Edition, Figure 34-2, page 544.

Chemical structure of oral anticoagulants structurally similar to vitamin K (analogues).

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

Refer to Katzung 10th Edition, Figure 34-5, pg. 550.

Mechanism of action

All agents depress the formation of functional forms of factors II (prothrombin), VII, IX and X by inhibiting the carboxylation of glutamic acid in these proteins which is essential for Ca+2 binding.

Refer to Katzung, 10th Edition, Figure 34-6, pg. 550.

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

Refer to Katzung, 8th Edition, Figure 34-7, pg. 571.

II. Dose:

1st day: 5 - 10 mg/d (Initial dosing).

2nd day: 5 - 7 mg/d (maintenance).

III. Route of administration:

All are well absorbed orally

IV. Fate:

Long T½ of the oral anticoagulants, due to binding to plasma albumin (warfarin is about 97% bound).

V. Metabolism:

1. Dicumarol and warfarin are hydroxylated to inactive compounds by the hepatic endoplasmic reticulum. 2. Metabolism varies greatly in patients.

VI. Therapeutic monitoring of oral anticoagulant drugs:

1. Warfarin depresses the functionality of vitamin K dependent factors (II, VII, IX and X). Thus, it impairs the blood coagulation in the extrinsic pathway. Prothrombin time (PT) is used to monitor the anticoagulant effects of warfarin. 2. A 1.5 time prolongation of the PT from the baseline is considered to be therapeutic. For example, if a patient's baseline PT is 12 seconds, he is considered in the therapeutic range around 18 seconds. 3. A patient with a lesser prolongation than 1.5 times the baseline is subtherapeutic and a dose increase may be necessary. 4. Reagent based variations have been noted in the prothrombin time. To obtain uniform degrees of anticoagulation, the concept of international normalized ratio (INR) has been introduced.

INR = PT (sec) patient ISI PT (sec) mean normal control

The INR can be used universally to adjust the level of anticoagulant in a given patient. Thus it helps in the optimization of dosage.

VII. Control of dose:

Many factors affect the dose of the oral anticoagulants.

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

1. Nutrition 2. Anemia 3. Liver disease 4. Biliary obstruction 5. Drugs

VIII. Drug interactions with warfarin:

1. Drugs cause warfarin potentiation:

a. by causing vitamin K deficiency. b. by displacing warfarin from protein binding sites. c. by decreasing clotting-factor synthesis d. by suppressing or competing for microsomal enzymes. e. by having antiplatelet aggregating properties.

2. Drugs reported to cause inhibition of the anticoagulant action of warfarin:

a. by decreasing warfarin absorption.

b. by enhancing warfarin metabolism.

Refer to Katzung 10th Edition, Table 34-2, pg. 551

. IX. Toxicity of Warfarin:

1. Principal toxicity is a marked hypoprothrombinemia resulting in ecchymosis, purpura, hematuria, hemorrhage.

2. All oral anticoagulants pass the placental barrier and may cause fetal malformation.

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Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin and November 1, 2012 Oral Anticoagulants D. Moorman

3. Warfarin also produces necrosis (Coumadin® induced necrosis). This is basically due to the impairment of the functionality of protein C. This protein also requires - carboxylation of glutamic acid for functionality.

4. Treatment of oral anticoagulant overdose.

a. Replacement of 4 factors. Infusion of whole fresh blood or frozen plasma. b. Recombinant factor VIIa c. Vitamin K

X. Vitamin K:

1. Naturally occurring fat-soluble vitamin found in green vegetables and synthesized by gut flora. These agents are structurally similar to the oral anticoagulants.

2. Function of vitamin K:

a. Essential to the attachment of a calcium binding functional group to prothrombin protein (presence of -carboxyglutamic acid). b. Required for the synthesis of clottable coagulation factors (II, VII, IX and X).

3. Therapeutic use:

a. Drug induced hypoprothrombinemia - antidote. b. Intestinal disorders and surgery (gastrectomy). c. Hypoprothrombinemias of newborn.

4. Toxicity - remarkably non-toxic:

High doses sometimes cause hemolysis in infants (mainly water soluble vitamin K).

XI. New Oral Anticoagulants*

1. Anti-Xa agents

a. Rivaroxaban (Xarelto) b. Apixaban

2. Antithrombin agents

a. Dabigatran

12 Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin and November 1, 2012 Oral Anticoagulants D. Moorman

Heparin & Low Molecular Weight Heparins Important Points to Remember

DRUG MECHANISM OF ROUTE OF ADMINISTRATION INDICATIONS SIDE EFFECTS ACTION Heparin Complex with AT and Mainly intravenous and also Surgical Anticoagulation Bleeding, HIT, inhibits factors Xa and given subcutaneous osteoporosis, alopecia IIa, Monitored by APTT Low Molecular Complex with AT and Mainly subcutaneous Prophylaxis and Treatment Bleeding Weight Heparins inhibits factors Xa and of DVT and ACS IIa Fondaparinux Complex with AT and Subcutaneous Management of DVT Bleeding (Pentasaccharide) inhibits factor Xa Argatroban Inhibits IIa Intravenous Anticoagulant management Bleeding of HIT patients Inhibits IIa Intravenous Anticoagulant management Bleeding Bivalirudin of HIT patients Inhibits IIa Intravenous Anticoagulant management Bleeding Hirudin of HIT patients Inhibits IIa Intravenous DIC, sepsis, thrombophilia, None Antithrombin hypercoagulable state Concentrate Protamine Sulfate Heparin antagonist Intravenous Reversal for Heparin Bradycardia, hypotens

Oral Anticoagulants Important Points to Remember

DRUG MECHANISM OF ACTION MONITORING INDICATIONS SIDE EFFECTS/ TOXICITY Warfarin Competitive antagonist of Prothrombin time/INR Prolonged treatment of Bleeding, coumadin vitamin K. Suppresses the DVT and Atrial induced necrosis synthesis of functional forms Fibrillation of factors II, VII, IX and X Vitamin K Cofactor in the synthesis of Not Required Hypoprothrombinemia, Hemolysis, functional forms of factors II, intestinal disorders and VII, IX and X, reverses gastrectomy warfarins effects Oral Anti-Xa Inhibits factor Xa Not Required Prophylaxis of DVT, Bleeding, liver toxicity - Rivaroxaban atrial fibrillation in the - Apixaban prevention of stroke

Oral Antithrombin Inhibits thrombin Not Required Prophylaxis of DVT, Bleeding, liver toxicity - Dabigatran atrial fibrillation in the prevention of stroke

13 Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin and November 1, 2012 Oral Anticoagulants.

TREATMENT OF THROMBOSIS: HEPARIN, LOW MOLECULAR WEIGHT HEPARIN AND ORAL ANTICOAGULANTS

Date: November 1, 2012-9:30 am Reading Assignment: Katzung 12th Ed., pp. 604-611

KEY CONCEPTS & LEARNING OBJECTIVES

1. To define the major classes of anticoagulant drugs with reference to their mechanism of action. 2. To describe the mechanism of the anticoagulant action of heparin with particular reference to its interaction with antithrombin. 3. To define the mechanism of protamine neutralization of heparin and to calculate the amount of protamine needed for the neutralization of the action of a given amount of heparin. 4. To know the differences between heparin and low molecular weight heparins. 5. To know the currently approved indications for low molecular weight heparins. 6. To understand the rationale of the use of low molecular weight heparins in the treatment of acute coronary syndromes and venous thrombosis. 7. To describe the laboratory tests needed for monitoring the actions of heparin. 8. To define the mechanism of anticoagulant action of the antithrombin agents and how it differs from heparin and low molecular weight heparin. 9. To understand the rationale for the use of direct thrombin inhibitors in the management of heparin induced thrombocytopenia. 10. To understand the mechanism of heparin-induced thrombocytopenia 11. To define the mechanism of action of oral anticoagulant drugs with particular reference to the role of -carboxylation of glutamic acid. 12. To describe major drug interactions with oral anticoagulant drugs. 13. To identify the role of vitamin K in the synthesis of coagulation factors II, VII, IX and X. 14. To describe the laboratory tests needed for monitoring the actions of oral anticoagulants. 15. To know the main clinical use of oral anticoagulant drugs. 16. To describe the mechanism of action of the new oral anticoagulants (dabigatran, apixaban and rivaroxaban).

LIST OF DRUGS COVERED IN LECTURE

1 Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin and November 1, 2012 Oral Anticoagulants.

A. Heparin (systemic anticoagulant) B. Low molecular weight heparin (enoxaparin, dalteparin, tinzaparin) C. Generic Enoxaparin D. Pentasaccharide (Arixtra®) E. Danaparoid (Orgaran®) F. Protamine sulfate G. Antithrombin-III H. Hirudin (Refludan®) I. Argatroban (Novastan®, Acova) J. Bivalirudin (Angiomax®) K. Warfarin (oral anticoagulant). L. Vitamin K M. Fresh frozen plasma N. Anti-Xa agents- Rivaroxaban, Apixaban O. Anti-IIa agents- Dabigatran

ALTERNATIVE THERAPIES

A. Compression devises B. TED (Thromboembolic Deterrent) stockings C. Foot Pump D. Exercise

2 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph. D.

ANTIPLATELET DRUGS

I. Pharmacology of platelet aggregation:

During platelet release reactions many pharmacologically active substances are secreted from the dense (Beta) and light (alpha) granules. In addition, many of the prostaglandin derivatives such as thromboxanes are formed. All of these substances exert a profound action on the overall function of platelets.

1. Light (alpha) granule release products:

a. Platelet factor 4

b. Beta-thromboglobulin

c. Platelet-derived growth factor (PDGF)

2. Dark (Beta) granule release products:

a. Ca+2

b. Serotonin (5-Hydroxytryptamine)

c. ATP/ADP

3. Products formed during platelet activation and endothelium interaction: prostaglandin derivatives, endoperoxides, thromboxanes.

II. Antiplatelet agents:

Antiplatelet agents - decrease platelet aggregation primarily in the arterial system.

1. Aspirin - antipyretic analgesic, decreased platelet aggregation, prolongs bleeding.

2. ADP Receptor inhibitors-Ticlopidine (Ticlid), Clopidogrel (Plavix) , Prasugrel (Effient) and Ticagrelor (Brilinta).

3. Propionic acid derivatives (NSAIDs)- Analgesic agents (also exhibit antiplatelet effects).

4. Dipyridamole (Persantine®)-a coronary vasodilator

5. Cilostazol (Pletal®) - a new drug for the management of intermittent claudication

6. GPIIb/IIIa Inhibitors (ReoPro®, Aggrastat® and Integrilin®)

1 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph. D.

7. Prostacyclin analogue (Iloprost®) and thromboxane receptor antagonists

8. Cyclooxygenase (COX) inhibitors (COX 1 and COX 2 inhibitors), Celebrex®, Vioxx® and Bextra

Platelet

GP IIb/IIIa

Tirofiban Aspirin, NSAIDs Eptifibatide Prasugrel Abciximab Ticagrelor Collagen Clopidogre Ticlopidine Cyclooxygenase-1 AA PGG2, PGH2 GP Ia/IIa TxA2 ADP PAR-1, Synthase TxA PAR-4 2 Fc?RIIa GPIb Thrombin cAMP AMP PGI2 5HT2 Receptor Phosphodiesterase Thromboxane receptor PDEI Serotonin TXRI

JF,WJ 2008

9. Anti-platelet drug combinations

a. Aspirin/clopidogrel, aspirin/prasugrel, aspirin/ticagrelor

b. Aspirin/GP IIb/IIIa inhibitor

c. Anticoagulant/antiplatelet drugs

d. Antiplatelet/thrombolytic drugs

e. Dipyridamole/aspirin

III. Clinical applications of antiplatelet drugs:

1. Cerebrovascular disease:

a. Transient ischemic attack (TIA)

2 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph. D.

b. Complete stroke

c. Carotid endarterectomy

d. Geriatric patients (institutionalized)

2. Coronary artery disease:

a. Acute myocardial infarction

b. Unstable angina

3. Saphenous vein coronary artery bypass grafts:

4. Peripheral vascular disease:

a. Venous thrombosis

b. Peripheral arterial disease (PAOD, intermittent claudication)

5. Small vessel disease:

a. Membrane proliferative glomerulonephritis

b. Thrombotic thrombocytopenic purpura

c. Other syndromes

6. Prevention of thrombus formation on artificial surfaces

IV. Drug interactions with antiplatelet agents:

1. Thrombolytic agents (urokinase, streptokinase and tissue plasminogen activator).

2. Heparin/LMW heparin/oral anticoagulants

3. Warfarin

4. Antithrombin agents (hirudin, bivalirudin and argatroban)

3 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph. D.

V. Pathways of Arachidonic Acid Release and Metabolism:

Refer to Katzung 11th Edition, Figure 18-1.

Arachidonic acid is metabolized by two major pathways:

1. Cyclooxygenase pathway

2. Lipoxygenase pathway

Both of these pathways and the epoxygenase(s) result in the formation of potent pharmacologic substances that can produce various pathophysiologic and physiologic responses. The products of the cyclooxygenase and lipoxygenase pathways produce different effects on blood vessels and blood cells. These include the following:

a. Vasoconstriction and vasodilation

b. Platelet aggregation and disaggregation

c. Leukocyte activation

4 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph. D.

d. Target site effects

VI. Cyclooxygenase Pathway: Refer to Katzung 11th Edition, Figure 18-2.

Aspirin inhibits both COX-1 and COX-2 thereby limiting the production of prostaglandins. In particular thromboxane formation in platelets is inhibited. This is the main mechanism by which aspirin mediates its therapeutic effects.

1. Regulation of prostacyclin and thromboxane synthesis.

a. Endothelial lining

b. Lipoproteins and other blood components

c. Diet

d. Drugs

5 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 Jawed Fareed, Ph. D.

e. Hemodynamic factors

GENERATION OF ARACHIDONIC ACID METABOLITES AND THEIR ROLES IN INFLAMMATION & THROMBOSIS

Kumar et al, p.37, Basic Pathology, 199.

VII. Pharmacology of Fish Oil

1. Active ingredients (omega-3 fatty acid).

a. -linolenic acid

b. eicosapentaenoic acid

c. docosahexaenoic acid

2. Mechanism of antiplatelet action.

a. Membrane effects.

b. Thromboxane A3 (inactive) formation

6 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 Jawed Fareed, Ph. D.

Antiplatelet Drugs Important Points to Remember

DRUG MECHANISM OF ROUTE OF INDICATIONS SIDE EFFECTS ACTION ADMINISTRATION

Aspirin COX Oral ACS, stroke,arterial thrombosis Bleeding, gastric irritatio Inhibitors Clopidogrel ADP receptor inhibitor Oral ACS, stroke, in stent Bleeding,TTP thrombosis Prasugrel ADP receptor Inhibitor Oral ACS, stroke, in stent, Bleeding thrombosis NSAIDS COX inhibitor Oral Various diseases Bleeding

Dipyridamole Phosphodiesterase Oral Arterial thrombosis/stroke Bleeding Inhibitor Cilostazol Phosphodiesterase Oral Intermittent claudication Hypotension Inhibitor Abciximab GP IIb/IIIa inhibitor Intravenous ACS/PCI Bleeding

Eptifibatide GP IIb/IIIa inhibitor Intravenous ACS/PCI Bleeding

Tirofiban GP IIb/IIIa inhibitor Intravenous ACS/PCI Bleeding

Ticagrelor ADP receptor inhibitor Oral ACS, stroke, in stent, Bleeding thrombosis

7 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph.D.

ANTIPLATELET DRUGS

Date: November 2, 2011 8:30 am Reading Assignment: Katzung 12th Ed., pp. 612-614 Katzung and Trevor’s Pharmacology, Examination & Board Review.8th Ed., pp. 157-162, pp. 286-287.

KEY CONCEPTS & LEARNING OBJECTIVES

1. To know the major antiplatelet drugs and their site of actions. 2. To describe the mechanism of action of aspirin and related inhibitors of cyclooxygenase. 3. To understand the mechanism of action of ADP receptor inhibitors (P2Y12), clopidogrel (Plavix®), Prasugrel (Effient) and Ticagrelor (Brilinta). 4. To know the use of antiplatelet drugs for the treatment of arterial thrombosis. 5. To know the mechanisms of action of the glycoprotein IIb/IIIa inhibitors (GPIIb/IIIa inhibitors). 6. To know the mechanism of the antiplatelet action of omega-3 fatty acids. 7. To understand the rationale of antiplatelet therapy used in the management of acute coronary syndromes. 8. To describe the laboratory tests useful in the monitoring of antiplatelet drugs. 9. To know the drug interactions between antiplatelet agents and other anticoagulant drugs

2 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph.D.

LIST OF DRUGS COVERED IN LECTURE:

1. Aspirin . 2. Ticlopidine (Ticlid®) 3. Clopidogrel (Plavix®) 4. Prasugrel (Effient) 5. Ticagrelor (Brilinta) 6. Dipyridamole (Persantine®) 7. Cilostazol (Pletal®) 8. Abciximab (ReoPro®) 9. Tirofiban (Aggrastat®) 10. Eptifibatide (Integrilin®) 11. Celebrex® (COX-2 inhibitor) 12. Vioxx® (COX-2 inhibitor) 13. Bextra® (COX-2 inhibitor) 14. Propionic acid derivatives (Ibuprofen) 15. Cangrelor (in development for IV use)

ALTERNATIVE THERAPIES

1. Fish oil emulsions 2. Gingko products 3. Garlic extracts 4. Soy products

2 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

PHARMACOLOGY OF THROMBOLYTIC AGENTS

I. INTRODUCTION TO FIBRINOLYTIC PROCESSES

Plasminogen Activators

Urokinase-type Liver Tissue-type Vascular endothelium Contact activation system

Plasminogen Plasmin

Inhibitors Plasmin activator

A. Activation and Inhibition of Blood Fibrinolytic System

Refer to Katzung 11th Edition Figure 34-3, pg. 590.

1 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

The fibrinolytic system is regulated by a variety of activators and inhibitors. A balance between the activators and inhibitors is important.

1. Physiologic Activators:

a. t-PA I Single chain tissue plasminogen activator

b. t-PA II Two chain tissue plasminogen activator

c. Pro Urokinase (SCUPA: Single chain urinary plasminogen activator)

d. Urokinase

The physiologic activators of plasminogen are able to convert endogenous plasminogen into plasmin. This action plays a key role in the dissolution of clots which are formed due to coagulation activation.

2. Physiologic Inhibitors:

a. PA-I Rapid-acting plasminogen activator inhibitor.

b. Thrombin activatable fibrinolytic inhibitor (TAFI)

c. lpha 2 - antiplasmin

d. lpha 2 - macroglobulin

e. C1 - esterase inhibitor

B. Physiologic Regulation of Fibrinolysis:

1. Molecular components:

a. Activators and inhibitors

b. Plasminogen (Pro-fibrinolysin)

Zymogenic form of the active enzyme plasmin single chain molecule (Mol. Wt. 88,000 Da). Composed of 790 amino acids. Native form is known as Glu-plasminogen. Plasmin cleaves the initial terminal 76 amino acids to form Lys-plasminogen.

2 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

c. Plasmin (Fibrinolysin)

Active protease capable of digesting both fibrinogen and fibrin. Formed by the cleavage of the Arg 560-Val bond by plasminogen activators.

C. Degradation of Fibrinogen and Fibrin by Plasmin

1. Fibrinogen can be degraded by plasmin:

FORMATION OF F.D.P.'S

A-ALPHA B-BETA FIBRINOGEN GAMMA D E D

FRAGMENT X + B Beta 1-42, A alpha fragments D E D

FRAGMENT D FRAGMENT Y

FRAGMENT E FRAGMENT D

Fragments X, Y, D and E are formed by the digestion of fibrinogen.

3 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

2. Fibrin:

Fibrin is formed by the action of thrombin on fibrinogen. Formed fibrin strands are stabilized by the action of Factor XIIIa. Plasmin acts on stabilized fibrin to form various products such as the DD/E, YD/DY and YY/E.

Fragments DDE, YD/DY and YYDD are formed by the action of plasmin on polymerized fibrin monomers (clots).

JF/RB, 2004.

Fragments DDE, YD/DY and YYDD are formed by the action of plasmin on polymerized fibrin monomers (clots).

D. Physiologic Control of Thrombolysis:

Several factors control physiologic fibrinolysis.

1. Factors that promote fibrinolysis:

a. Plasminogen incorporation into thrombus via fibrin binding

b. Clot retraction

c. Local release of t-PA by endothelial cells

d. Binding of t-PA to fibrin

e. Enhanced t-PA or UK activity in the presence of fibrin

f. Protection of bound plasmin from antiplasmin

4 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

2. Factors Which Limit Fibrinolysis:

a. Fibrin crosslinking by Factor XIIIa

b. Binding of alpha2-antiplasmin to fibrin

c. Low ratio of endothelial surface to thrombus volume in large vessels

d. Efficient inhibition of free plasmin by antiplasmin

e. Antiplasmin impairs plasmin binding to fibrin.

E. Fibrinolytic Balance: Thrombosis vs. Bleeding

An intricate balance in the fibrinolytic process maintains the blood in the fluid state. Either thrombotic or bleeding complications can result if the balance is not maintained.

II. THROMBOLYTIC THERAPY

A. Introduction:

Comprised mainly of plasminogen activators. Several thrombolytic agents are now clinically used for the dissolution of clots (thrombi). Degradation of clots produce the following effects:

1. Reduction in thrombus size (thrombolytic)

2. Reduction of fibrinogen levels

3. Increase in the fibrinogen and fibrin degradation products

4. Antiplatelet activators

B. Classification of Thrombolytic Agents:

The thrombolytic agents can be classified according to their development and clinical usage.

1. Clinically approved thrombolytic agents

a. Urokinase-Approved in Canada and Europe

b. Streptokinase

c. Recombinant tissue plasminogen activators

5 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

- Alteplase (Human t-Pa)

- Reteplase (Mutant form of human t-Pa, more fibrin specific)

- Tenecteplase (Mutant form of human t-Pa with a longer half life)

2. Other thrombolytic agents

a. Acylated plasminogen: streptokinase activator complex (Anistreplase) (Discontinued in USA)

b. Single chain pro urokinase (Pro-UK, SCU-PA) (Under development)

c. Plasmin (Under development)

C. Practical Aspects of Thrombolytic Therapy

Effects of various thrombolytic agents can be depicted in the following figure. Fibrinolytic processes can occur in blood (plasmatic) and on the thrombus.

In Blood In Thrombus Plasma Fibrin-Bound Plasminogen Plasminogen

T-PA scu-PA APSAC UK SK

Plasmin Plasmin

Antiplasmin

Fibrinogen degradation (“Lytic State”) Fibrin degradation (Thrombolysis)

6 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

1. Development of the plasma fibrinolytic state: Several biological changes occur after the administration of thrombolytic agents. Some of these are listed below:

a. Circulating plasminogen activator

b. Plasminogen converted to plasmin

c. Antiplasmin complexes with and inhibits plasmin

d. Free plasmin

e. Plasmin degradation of fibrinogen

f. Degradation of other plasma clotting factors

g. Hypocoagulable state

2. Major effects of Thrombolytic Therapy:

Besides dissolving the clots, thrombolytic agents produce multiple actions. Some of these can be summarized in the following:

EFFECT EVENT PATHOGENESIS Clinical Benefit Thrombolysis Degradation (solubilization) of fibrin in the thrombus Side-effect Systemic lytic state Degradation of plasma fibrinogen by circulating plasmin Complication Bleeding Degradation of fibrin in hemostatic plugs (possibly also the hypocoagulable state) adversely influenced by prolonged duration of treatment

JF

7 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

Effect of Thrombolytic Therapy on the Fibrinogen and Plasminogen Levels (Note the decrease in fibrinogen after thrombolytic agents).

JF

8 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

3. Clinical Usage of Thrombolytic Agents:

Thrombolytic agents are now routinely used for a variety of thrombotic conditions. Their clinical acceptance is gradually increasing.

a. Acute Myocardial Infarction:

Large numbers of patients with myocardial infarction have a thrombus in the coronary vessels, with the incidence of occlusion being 70% after the onset of pain. Several thrombolytic agents are currently used for the treatment of myocardial infarction.

1. Narrow Lumen (Atherosclerosis)

4. Fibrin formation

2. Platelet burden

3. Tissue Factor release

Acute occlusion of the coronary artery leading to the formation of a fibrin-rich clot, which may lead to myocardial infarction.

A fresh thrombosis in the coronary artery. Platelet aggregates forming of a thrombus resulting in plaque rupture leading to a fresh clot formation and a myocardial infarction.

Time plays a crucial role for the success of thrombolytic therapy. Older clots are less susceptible to the lytic action of thrombolytic agents.

b. Peripheral Arterial Occlusion:

Thrombolytic agents such as urokinase and streptokinase have been routinely used in the dissolution of arterial occlusions. Both intravenous and localized treatments are used.

c. Deep Venous Thrombosis:

Both streptokinase and urokinase were initially used for the treatment of DVT. Both localized and systemic treatment can be used.

d. Pulmonary Embolism: 9 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

Both streptokinase and urokinase were originally used in large multicenter clinical trials in the U.S.A. Both local and systemic infusions of streptokinase and urokinase have been used. t-PA is not used in this indication.

e. Thrombotic stroke. Acute management of thrombolytic and ischemic stroke

f. Catheter Clearance:

For shunts, grafts and extracorporeal circulation, these agents offer very efficient cleansing effects.

D. Clinical Results on the Use of Thrombolytic Agents in Myocardial Infarction:

Thrombolytic agents have been successfully used in various conditions such as DVT, pulmonary embolism, peripheral occlusive disorders and other thrombotic conditions.

E. Complications of Thrombolytic Therapy:

1. Bleeding

2. Re-occlusion

3. Stroke

4. Others

F. Absolute Contraindication of Thrombolytic Therapy:

1. Intracranial bleeding

2. Massive hemorrhage

G. Other Contraindications

H. Drug Interactions with Thrombolytic Agents:

1. Antiplatelet Drugs

2. Heparin

3. Dextrans

10 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

I. Pharmacologic Antagonist for Thrombolytic Agents:

1. EACA (Epsilon-amino caproic acid)

2. Tranexemic Acid (Trans-4-Aminoethylcyclohexane 1-Carboxylic Acid) 3. Aprotonin (Trasylol)

III. DEFIBRINOGENATING ENZYMES

A. General Considerations:

A number of venoms and biologics contain enzymes that can digest fibrinogen. Some of these agents have been found to be useful for therapeutic purposes.

1. Ancrod is tested in stroke

IV. CORONARY ANGIOPLASTY AND STENTS

A. Anticoagulants during coronary angioplasty.

B. Stents

1. Bare metal stents

2. Drug eluting stents

3. Disposable stents

11 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

Thrombolytic Agents Important Points to Remember

DRUG MECHANISM OF ROUTE OF INDICATIONS SIDE ACTION ADMINISTRATION EFFECTS

Streptokinase Fibrinolytic Intravenous Thrombolysis, stroke, MI, Bleeding PE Urokinase Fibrinolytic Intravenous Thrombolysis, stroke, MI, Bleeding PE Tissue plasminogen Fibrinolytic Intravenous Thrombolysis, stroke, MI Bleeding activator Epsilon amino caproic Anti-fibrinolytic Intravenous Reversal of bleeding Hypotension acid (AMICAR)

Aprotonin (Trasylol) Anti-fibrinolytic Intravenous Reversal of bleeding Graft thrombosis

Ancrod Fibrinolytic Intravenous Stroke Allergic reaction

Tranexamic acid Anti-fibrinolytic Intravenous Reversal of bleeding Retinopathy (AMCHA)

12 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D.

PHARMACOLOGY OF THROMBOLYTIC AGENTS

Date: November 2, 2012-9:30 am Reading Assignment: Katzung, B.G., 12th Ed., pp.611-612.

KEY CONCEPTS AND LEARNING OBJECTIVES

1. To know the different components of the fibrinolytic system in terms of inhibitors, activators and zymogens. 2. To distinguish between the plasmin mediated degradation of fibrinogen and fibrin. 3. To know the role of plasminogen in fibrinolysis. 4. To know the physiologic activators of plasminogen with particular reference to the role of endothelial t-PA in physiologic thrombolysis. 5. To know the site of action of different thrombolytic agents. 6. To describe the side effects of thrombolytic therapy. 7. To know the antagonists that can be used for neutralizing the actions of thrombolytic agents. 8. To know the possible interactions of thrombolytic agents with aspirin and heparin 9. To know which laboratory tests can be used for the monitoring of thrombolytic agents.

LIST OF DRUGS COVERED IN LECTURE:

1. Urokinase 2. Streptokinase 3. Streptokinase Plasminogen Complex (Anistreplase, Eminase) 4. Tissue plasminogen activators (Alteplase, Reteplase, Tenecteplase) 5. Pro-urokinase 6. Epsilon amino caproic acid 7. Tranexamic acid 8. Ancrod 9. Aprotinin

ALTERNATIVE THERAPIES

1. Atherectomy 2. Stents 3. Rotoablation

1 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

#26-27 - INTRODUCTION TO ANTIBIOTICS

Appropriate antimicrobial therapy for a given infectious disease requires knowledge of the potential site of infection; the infecting pathogen(s); the expected activity of the antibiotic(s) against the infecting pathogen(s); and host characteristics. Therefore, appropriate diagnosis is crucial. Specimens should be obtained from the suspected site of infection (optimally BEFORE antibiotics are initiated) for microscopy and culture to try and identify the causative pathogen(s).

I. ESTABLISHING THE PRESENCE OF INFECTION – Before initiating antibiotic therapy, it is important to first clearly establish the presence of an infectious process. The isolation of an organism from a clinical specimen does not always indicate the presence of infection or mandate anti-infective therapy. A. NORMAL FLORA, CONTAMINATION, COLONIZATION, OR INFECTION 1. The human body harbors a number of microorganisms that colonize certain body systems called “normal flora”, which are normally harmless bacteria that occur naturally on the skin, and in the respiratory, gastrointestinal, and genitourinary tracts. a. Normal flora bacteria are located in anatomic sites where pathogenic organisms can cause disease. They often compete with pathogenic organisms for nutrients, stimulate cross-protective antibodies, and suppress the growth of pathogenic organisms. b. Bacteria that comprise normal flora may become pathogenic when host defenses are impaired or when they are translocated to sterile body sites during trauma, intravenous line insertion, or surgery (necessitating skin disinfection before line insertion or surgery). c. Indiscriminate use of antibiotics can alter or eradicate the protective normal bacterial flora. d. Patients who are hospitalized for more than 48 hours can have their usual normal flora replaced by the “normal flora” of the hospital, which tend to be gram-negative aerobes. e. SITES OF NORMAL FLORA COLONIZATION

SKIN UPPER RESPIRATORY TRACT Diphtheroids (Corynebacterium spp.) Bacteroides spp. Propionibacteriaceae Haemophilus spp. Bacillus spp. Neisseria spp. Staphylococci (esp. coagulase-negative) Streptococci (anaerobic) Streptococci GASTROINTESTINAL TRACT GENITOURINARY TRACT Bacteroides spp. Lactobacillus spp. Clostridium spp. Corynebacterium spp. Enterobacteriaceae (E. coli, Klebsiella spp.) Enterobacteriaceae – especially E.coli Streptococci (anaerobic) Staphylococci (S. saprophyticus) Enterococcus spp. Streptococci Fusobacterium spp.

1 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

2. BODY SITES THAT ARE STERILE include the bloodstream, cerebrospinal fluid, pleural fluid, peritoneal fluid, pericardial fluid, synovial fluid, bone, and urine (taken directly from the bladder). 3. The isolation of an organism from a clinical specimen does not always represent the presence of infection - clinicians must consider the clinical, laboratory and radiographic evidence available to differentiate between contamination, colonization, or infection. a. Contamination – an organism is introduced into the clinical specimen during the sample acquisition process i. Example: isolation of coagulase negative staphylococci in the blood of a patient where the blood was drawn via a peripheral stick and the patient does not have signs of infection (normal skin flora bacteria contaminated blood culture). b. Colonization – an organism is present at a body site but is not invading host tissue or eliciting host responses. i. Example: isolation of Pseudomonas aeruginosa from a sputum culture in a patient without fever, cough, or infiltrate on chest x-ray (pathogenic bacteria in patient without clinical/radiologic signs of pneumonia). c. Infection – a pathogenic organism is present at a body site and is damaging host tissues and eliciting host responses and symptoms consistent with infection. i. Example: isolation of Streptococcus pneumoniae in the cerebrospinal fluid of a patient with fever, headache, photophobia, and neck stiffness. 4. Clinical signs of infection (both localized and systemic) include:

LOCALIZED SYSTEMIC pain purulent discharge FEVER malaise inflammation sputum production chills, rigors hypotension swelling cough tachycardia mental status changes erythema abnormal discharge tachypnea

5. Laboratory signs suggestive of infection include: a. Elevated white blood cell count (peripheral {leukocytosis} and/or at site of infection) with a “left shift” b. Positive gram stain and culture c. Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) d. Positive antigen or antibody titers 6. Radiographic signs of infection a. Infiltrate on chest x-ray in patients with pneumonia b. Periosteal elevation and bony destruction on a bone x-ray in a patient with osteomyelitis 7. Assessment of the Severity of Infection a. The severity of a patient’s infection is based on the degree of abnormality in the parameters above.

2 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

b. Significant alterations in cardiac, respiratory and central nervous system parameters may signify a serious, life-threatening infection. c. The severity of infection may influence the choice, route of administration, and dose of antibiotics used. 8. Common Bacterial Pathogens by Site of Infection a. Certain bacteria have a propensity to commonly cause infection in particular body sites or fluids. b. This information is used to guide the choice of empiric antibiotic therapy before the results of the gram stain, culture, and susceptibility results are known. An antibiotic is empirically chosen that has a spectrum of activity that covers the most common causative bacteria at the patient’s suspected infection site.

SUSPECTED ORGANISMS BY SITE OF INFECTION Mouth Skin & Soft Tissue Bone & Joint Peptococcus Staphylococcus aureus Staphylococcus aureus Peptostreptococcus Staphylococcus epidermidis Staph epidermidis Actinomyces israelii Streptococcus pyogenes Neisseria gonorrhoeae Treponema pallidum Pasteurella multocida Streptococcus spp. Gram-negative bacilli Abdomen Urinary Tract Upper Respiratory Tract Escherichia coli Escherichia coli Streptococcus pneumoniae Proteus spp. Proteus mirabilis Haemophilus influenzae Klebsiella spp. Klebsiella spp. Moraxella catarrhalis Enterococci Enterococcus spp. Streptococcus pyogenes Bacteroides spp. Staphylococcus saprophyticus Fusobacterium spp. Lower Respiratory Tract Lower Resp Tract Meningitis Community-Acquired Hospital-Acquired Streptococcus pneumoniae Staphylococcus aureus (MRSA) Streptococcus pneumoniae Haemophilus influenzae Pseudomonas aeruginosa Neisseria meningitidis Klebsiella pneumoniae Acinetobacter sp. Klebsiella pneumoniae Enterobacter spp. Haemophilus influenzae Legionella pneumophila Citrobacter spp. Group B Strep Mycoplasma pneumoniae Serratia spp. Escherichia coli Chlamydophila pneumoniae Acinetobacter spp. Listeria monocytogenes Moraxella catarrhalis Staphylococcus aureus

When selecting an antibiotic for a particular infection, one of the issues that will be considered is the result of antimicrobial susceptibility testing of the infecting pathogen, which typically takes 24 to 48 hours or more to perform. If the susceptibility results of the infecting pathogen are not yet known, an antibiotic is empirically selected based on the most likely infecting organism and current local susceptibility patterns. In most cases, therapy must be initiated at the suspicion of infection since infectious diseases are often acute, and a delay in treatment may result in serious morbidity or even mortality (e.g., meningitis, pneumonia). Once the susceptibility results of the infecting bacteria are known, empiric antibiotic therapy should be streamlined to an antibiotic agent with more specific activity toward the infecting bacteria.

3 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

II. ANTIMICROBIAL SUSCEPTIBILITY TESTING

A. General Antimicrobial Spectrum of Activity - the spectrum of activity for each antibiotic is a general list of bacteria that the antibiotic displays activity against. However, since bacteria may become resistant to antibiotics over time, recent national, local, and specific organism susceptibility data should be considered when selecting an antibiotic to treat a specific patient’s infection. 1. Narrow Spectrum: the antibiotic has activity against a limited group of bacteria (e.g., penicillin has activity against some gram-positive and gram- negative cocci, but not gram-negative bacilli). 2. Broad Spectrum: the antibiotic has activity against a wide variety of bacteria, such as gram-positive and gram-negative bacteria (e.g., imipenem has activity against gram-positive and gram-negative aerobes and anaerobes).

B. Susceptibility Definitions 1. Minimum Inhibitory Concentration or MIC– the lowest concentration of an antibiotic that prevents visible growth (unaided eye) of a bacteria after 18 to 24 hours of incubation 2. Minimum Bactericidal Concentration or MBC – the lowest concentration of an antibiotic that results in a decrease of > 99.9% of the bacterial inoculum (MIC  MBC) 3. Susceptibility Breakpoints – interpretive guidelines established by the Clinical and Laboratory Standards Institute (CLSI) that categorize the MIC values or zone sizes for each antibiotics against each bacteria as: a. Susceptible (S) – organism will most likely be eradicated during treatment of infection using normal doses of the specified antibiotic; concentrations of the antibiotic represented by the MIC are easily achieved in patient’s serum with usual doses. b. Intermediate (I) – results are considered equivocal or indeterminate; MICs are higher, and treatment may be successful when maximum doses are used or if the drug concentrates at the site of infection. c. Resistant (R) – indicates less than optimal results are anticipated if the particular antibiotic is used; the MIC exceeds usual serum concentrations (even if maximal doses are used). d. The interpretive guidelines for S, I, and R of each antibiotic are often different because they are based on clinical PK of the individual drug (achievable serum and tissue concentrations), general activity of the antibiotic, site of infection, and data from clinical efficacy trials. e. Susceptibility breakpoints differ for each antimicrobial drug class and even between antibiotics within the same drug class – therefore, MIC values often cannot be compared between antibiotics.

C. TESTING METHODS FOR SUSCEPTIBILITY - once an organism is cultured in the microbiology lab, further testing is performed to determine the antibiotic susceptibility of the organism to serve as a guide to streamline antibiotic therapy. 1. Broth Dilution (macrodilution with test tubes, microdilution with automated microtiter plates or cassettes) – a quantitative determination of the in vitro activity of an antibiotic since an exact MIC or MIC range can be determined 4 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

a. Dilutions of an antibiotic (based on achievable serum concentrations after usual doses) are placed in broth with a standard inoculum of the infecting bacteria and incubated for 18 to 24 hours. b. MIC = the lowest concentration of an antibiotic that prevents visible growth of the infecting bacteria after 18 to 24 hours of incubation (clear to unaided eye with macrodilution; automated systems by the machine). c. Macrodilution testing employs two-fold serial dilutions of an antibiotic (based on achievable serum concentrations after usual doses) incubated in test tubes with a standard inoculum of the patient’s infecting bacteria; the exact MIC of the antibiotic is the first tube without visible growth; labor and resource intensive. i. MBC – lowest concentration of the antibiotic that kills bacteria  Test tubes without visible growth are cultured on agar plates, after incubation colonies counted - MBC is the concentration that reduced the original inoculum by 99.9% after 24 hours of incubation.  MBC is only determined in limited circumstances such as in the treatment of some infections where bactericidal activity may be more predictive of a favorable outcome (meningitis, endocarditis).

With permission from: A Practical Approach to Infectious Diseases, 4th edition, 1996, page955

d. Microdilution methods employ microtiter plates or cassettes that contain wells with serial dilutions of several antibiotics that can be tested for susceptibility simultaneously in an automated system. e. Size constraints of the plates or cassettes allow only a limited number of concentrations to be tested for each antibiotic (usually those representing the S, I, and R breakpoints), so that an MIC range may be reported instead of an exact MIC (for example  8 g/ml, susceptible). f. Automated microdilution systems are the most common method utilized in microbiology labs for susceptibility testing because less labor and resources are required for performance.

5 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

2. Disk Diffusion (Kirby Bauer Method) – a qualitative determination of the in vitro activity of an antibiotic a. Filter paper disks impregnated with a fixed concentration of an antibiotic are placed on agar plates inoculated with a standardized inoculum of the patient’s infecting bacteria. b. Bacteria multiply on the plate while antibiotic diffuses out of the disk; bacterial growth occurs only in areas where drug concentrations are below those required to cause inhibition of bacterial growth. c. A clear zone of inhibition is then observed around the disk - the larger the diameter, the more active the drug against the bacteria. Zone diameters in millimeters (mm) for each drug have been correlated to susceptible and resistant interpretations; however, exact MICs cannot be determined.

With permission from: Diagnostic Microbiology, 12th edition, 2007, page 195

3. E-Test (Epsilometer Test) – combines the quantitative benefits of microdilution with the ease of agar dilution a. A plastic strip impregnated with a known, prefixed concentration gradient of antibiotic is placed on an agar plate with a standardized inoculum of the patient’s infecting bacteria. b. Bacteria multiply on the agar plate while antibiotic diffuses out of the strip according to the concentration gradient; bacterial growth occurs only in areas where drug concentrations are below those required to cause inhibition of bacterial growth. c. An elliptical zone of inhibition is then formed, and the MIC is measured where the ellipse crosses the antibiotic strip. An exact MIC can be determined.

6 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

With permission from: Diagnostic Microbiology, 12th edition, 2007, page 200

4. Susceptibility Reports a. For each patient’s infecting bacteria, a susceptibility report will be generated that lists the antibiotics that were tested for activity against the organism, the exact MIC or zone size (or MIC range if automated systems are used) and CLSI interpretation (S, I, and R). b. This information is utilized with other clinical and patient-specific parameters (to be discussed later) to select an antibiotic regimen for the treatment of the patient’s infection. 5. Hospital Antibiograms a. Susceptibility data from organisms cultured from patients (inpatients and/or outpatients) are compiled in an annual report called an Antibiogram. b. The susceptibility data in an antibiogram is typically used to help guide the choice of empiric antibiotic therapy before the infecting organism has been identified in the lab. Clinicians use the antibiogram to determine the most active antibiotic against specific organisms at that specific institution.

III. HOW ANTIBIOTICS ARE USED

A. The treatment of infectious diseases is quite different than other disease states requiring drug therapy in a number of ways: 1. Antibiotics can be used to treat a suspected or documented infection, or can be used to prevent an infection from occurring in high-risk patients. 7 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

2. Additionally, anti-infective therapy is typically given for a finite duration of therapy or a particular number of days based on previous clinical data for that infection type and/or infecting organism. Occasionally, some patients may receive anti-infective therapy for an infinite duration (such as that given for diabetes, CHF, or hypertension).

B. Empiric Therapy – Antibiotics are administered that have activity against the predicted or most likely pathogens causing a patient’s infection based on the signs and symptoms of infection. The site of infection may or may not be known, and the culture results are pending, negative, or unobtainable. 1. Examples – antibiotics are started in a patient with community-acquired pneumonia who is unable to expectorate a sputum sample; a patient presents to the hospital with signs of bacterial meningitis and antibiotics are started immediately after a lumbar puncture is performed. 2. The initial antibiotic therapy is selected based on the known or probable site of infection, the most likely causative organism(s), the drug of choice for that particular organism and infection, and the local (hospital antibiogram) or regional susceptibility patterns of the suspected bacterial pathogens. Empiric antibiotic therapy usually covers a wide variety of bacteria (broad-spectrum). 3. Empiric therapy is usually administered until the culture and susceptibility results are available. If an organism is not isolated, empiric therapy may be continued until the finite duration of antibiotic therapy has been completed for that infection type, assuming the patient is improving.

C. Directed or targeted therapy – antibiotics are used to treat an established infection where the site of infection, causative pathogen, and antibiotic susceptibilities are known. 1. Example – a patient has bacteremia with methicillin-susceptible Staphylococcus aureus and is receiving intravenous nafcillin therapy. 2. Antibiotic therapy is selected based upon the susceptibility results of the infecting pathogen, and is typically changed from the empiric antibiotic originally chosen to a more narrow-spectrum agent directed toward the infecting organism. 3. Antibiotics are given for the finite duration of therapy as determined by the infection type. All effective antibiotics that have been administered for the infection count toward the effective days of therapy (empiric and directed).

D. Prophylactic Therapy – antibiotics are given to prevent the development of infection during a procedure or immunocompromised state when there is a considerable risk of infection 1. Examples – a patient with damaged heart valves is given amoxicillin to prevent endocarditis at the time of a bacteremia-inducing dental procedure; an AIDS patient is given Bactrim to prevent Pneumocystis carinii pneumonia 3 when the CD4 count is less than 200 cells/mm ; antibiotics are given prior to surgical procedures to prevent surgical site infections 2. Antibiotic therapy is selected based on the local and regional susceptibility patterns of the most likely infecting bacteria.

8 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

3. Prophylaxis is administered for as long as the patient is at risk, such as single dose antibiotic therapy for surgical/dental prophylaxis or longer durations of antibiotic therapy during immunosuppressive states.

E. Combination Therapy 1. Combination therapy may be selected in a limited number of circumstances for the treatment of infection: a. To provide coverage against all organisms in a mixed, polymicrobial infection where a single antibiotic does not cover all of the infecting organisms – used to broaden bacterial coverage. b. To take advantage of synergistic properties when the antibiotics are used together. c. To decrease the emergence of resistance – only for tuberculosis. 2. Synergy – the activity of the antimicrobial combination is greater than that expected from the additive activity of the individual antimicrobials a. (A + B) > A + B b. Example: ampicillin and gentamicin are administered together in the treatment of Enterococcal endocarditis in order to produce bactericidal activity and achieve successful eradication of the infection (alone each agent is bacteriostatic against Enterococcus) 3. Additive – the activity of the antimicrobial combination is no greater than the sum of the effects of each individual component (no greater and no worse) a. (A + B) = A + B 4. Antagonism – the activity of the antimicrobial combination is less than that expected from the additive activity of the individual antimicrobials a. (A + B) < A + B b. Example: azole antifungals and amphotericin B

IV. PHARMACODYNAMIC CONSIDERATIONS

A. Type of antibacterial activity – BACTERIOSTATIC or BACTERICIDAL? 1. Bacteriostatic – antimicrobial agents that inhibit the growth of susceptible bacteria and rely on host defenses to help kill the bacteria and subsequently eradicate the infection a. Typically, normal host defenses are required for clinical success of bacteriostatic agents, so they should be used with caution in patients who are immunocompromised. b. Examples: macrolides, ketolides, streptogramins, oxazolidinones, tetracyclines, glycylcyclines, sulfonamides (alone), and clindamycin 2. Bactericidal – antimicrobial agents that kill susceptible bacteria in the absence of host defenses a. Bactericidal activity is considered essential in the treatment of infections located in sites where host defenses are not adequate including the meninges (meningitis), heart valves (endocarditis), and bone (osteomyelitis); as well as in patients with impaired host defenses (febrile neutropenia). b. Examples: -lactams, aminoglycosides, vancomycin, daptomycin, fluoroquinolones, metronidazole, and trimethoprim-sulfamethoxazole

9 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

B. Pharmacodynamics (PD) is the study of the time course or rate of bacterial killing relative to serum concentrations. The study of pharmacodynamic provides a rational basis for optimizing dosing regimens by describing the relationship between drug, host, and antimicrobial effect by integrating both pharmacokinetic and MIC data.

Concentration Pharmacolgic or versus time in tissue toxic effect Concentration and other body fluid Dosage versus time in Regimen serum Concentration Antimicrobial versus time at site effect versus time Absorption of infection Distribution Elimination

Pharmacokinetics Pharmacodynamics

C. PD studies have demonstrated marked differences in the time course of bacterial killing among different antibiotics, described by examining the relationship between pharmacokinetic parameters and the MIC.

D. On the basis of PD studies, antibiotics can generally be divided into 2 major groups on the basis of their bactericidal activity: 1. Concentration-dependent – the higher the serum concentration of the antibiotic, the more rapid and extensive the degree of bacterial killing. Concentration-dependent agents also appear to have prolonged persistent effects (post antibiotic effects or PAE) that allow for infrequent dosing. a. Examples of concentration-dependent antibiotics include the aminoglycosides, the fluoroquinolones, daptomycin, and metronidazole b. The major PD parameters that correlate with clinical and microbiologic outcome (efficacy) of concentration-dependent antibiotics are the Peak/MIC ratio and the AUC/MIC ratio. c. Goal of dosing - infrequent dosing of large doses to maximize drug concentrations or magnitude of exposure for optimal bacterial killing. 2. Concentration-independent (time-dependent) – higher serum concentrations of the antimicrobial do not produce enhanced bacterial killing. The extent of bacterial killing is largely dependent on the time of exposure. These agents are not rapidly bactericidal, and typically have a short or nonexistent PAE. a. Examples include the -lactams, clindamycin, macrolides, ketolides, vancomycin, tetracyclines, linezolid, Synercid b. Goal of dosing - optimize the duration of exposure (Time>MIC). Maintain the serum concentrations of the antibiotic above the MIC for the infecting pathogen for at least 40-70% of the dosing interval, depending on the organism.

10 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

E. Post-Antibiotic Effect (PAE) – the time it takes for a bacteria to recover after exposure to an antibiotic, or the time it takes for bacteria to recover and begin regrowth after an antibiotic has been removed. 1. The exact duration of the PAE is drug and organism specific. 2. Agents with appreciable PAEs may be dosed to allow serum concentrations to fall below the MIC of the infecting bacteria since regrowth will not occur for a finite period (for as long as the antibiotic’s PAE). 3. All antibiotics produce some PAE against gram-positive bacteria; the PAE for -lactams is approximately 2 hours. 4. For gram-negative bacteria, prolonged PAEs are observed after exposure to protein synthesis inhibitors or nucleic acid synthesis inhibitors (fluoroquinolones and aminoglycosides); -lactams have short or nonexistent PAE.

V. ANTIMICROBIAL REGIMEN SELECTION

A. Choosing an antibiotic to treat a patient’s infection is more complicated than simply matching a drug to a known or suspected pathogen. The decision is typically based on the interrelationship between the patient, the infection, and the characteristics of the antibiotic.

B. When selecting an antibiotic for the treatment of an infection, a variety of factors must be considered: 1. Infection-Specific Factors a. Severity of infection (mild. moderate, severe, life-threatening) – influences the route of administration, dose, number of antibiotics Oral – for infections that are mild, or for those that are significantly improved and can be treated on an outpatient basis IV – used for infections that are serious or life-threatening, or for antibiotics with insufficient absorption from the GI tract. b. Site of infection – influences the antibiotic and dose, since adequate concentrations of the drug must reach the site of infection for efficacy. Special considerations must be made for the treatment of meningitis (cross blood-brain barrier), endocarditis, prostatitis, etc. c. Infecting organism – site of acquisition of the infection (community versus hospital, nursing home); exposure to ill family members, pets; employment; recent travel; known or anticipated susceptibility patterns; empiric versus directed therapy; drug of choice for particular organism/infection; need for combination therapy 2. Host Factors – patient-specific characteristics should be considered in every patient in whom antimicrobial therapy will be instituted a. Allergies – careful assessment of allergy history should be performed to ascertain the potential antimicrobial agents that may be used for a patient’s infection. i. A careful allergy history is necessary because many patients confuse common adverse effects with true allergic reactions (GI effects such as nausea, vomiting, or diarrhea).

11 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

ii. The most common antibiotic allergy is to the penicillins; must consider the allergic reaction as well as the degree of cross- reactivity to other -lactam antimicrobials. iii. Allergy to a specific antibiotic precludes the use of that antibiotic (and often antibiotic class) for the treatment of infection. Typically, allergy to one macrolide precludes the use of other macrolides, and the same holds true for other antibiotics among the same class. b. Age – aids in identification of the causative pathogen, as well as assessing the patient’s ability to eliminate antimicrobial agents. i. The causative pathogen in meningitis varies markedly depending on the age of the patient. ii. The pharmacokinetics (PK) of different antibiotics may be altered based on the age of the patient including protein binding, metabolism, or renal elimination of an antimicrobial agent, which may influence drug selection or drug dosing.  Premature neonates develop kernicterus from sulfonamides due to displacement of bilirubin from albumin.  Renal function (and elimination) declines with age.  Age-related hepatotoxicity with isoniazid. c. Pregnancy and nursing – the fetus is at risk for teratogenicity during pregnancy and adverse effects while nursing during antibiotic therapy with some agents. Also, PK parameters are altered during pregnancy (increased volume of distribution and clearance for some drugs) and must be taken into account when dosing. d. Renal and hepatic function – patients with diminished renal or hepatic function will accumulate certain anti-infectives, which may lead to undue toxicity. Dosage adjustments are necessary ensure efficacy but avoid undue toxicity. i. Antibiotics primarily eliminated by the kidney include most - lactams (except nafcillin, oxacillin, ceftriaxone, cefoperazone); most fluoroquinolones, clarithromycin, aminoglycosides, vancomycin, daptomycin, Bactrim, and tetracycline. Dosages can be adjusted according to predetermined guidelines. ii. Some antibiotics may be removed during a hemodialysis session and require supplemental dosing. iii. Liver dysfunction will alter the elimination of chloramphenicol, clindamycin, metronidazole, nafcillin/oxacillin, linezolid, Synercid, erythromycin, azithromycin, doxycycline, tigecycline, and Bactrim. Dosage adjustments in this setting are not well-studied. e. Concomitant drug therapy may influence the antibiotic used, the dose, or monitoring (occurrence of a drug-drug interactions) i. Augmented toxicity – coadministration of drugs may increase the likelihood of toxicity (vancomycin and gentamicin  nephrotoxicity; ganciclovir and zidovudine  neutropenia) ii. Altered PK – coadministration may alter the A, D, M, and E of either agent (divalent cations decrease the absorption of fluoro- 12 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

quinolones and tetracyclines   concentrations and treatment failure) f. Underlying disease states influence antibiotic selection by predisposing the patient to certain infections or particular causative pathogens related to their disease state. i. Patients with diabetes or peripheral vascular disease are prone to soft tissue infections of the lower extremities; patients with chronic lung disease are prone to pulmonary infections. ii. Underlying immunosuppression (malignancy, acquired immunodeficiencies) may lead to a wide variety of infections due to a number of etiologic agents. iii. Disruption of integumentary barriers from burns, trauma, or iatrogenic wounds (surgery, intravascular lines) may increase the risk of infection. 3. Drug Factors – the individual characteristics of each antibiotic must be considered when selecting the most appropriate agent a. In vitro spectrum of activity and current susceptibilities – antibiogram, national, regional, or local b. Clinical efficacy as demonstrated by FDA-approved indications or other clinical studies in the published literature c. Drug of choice charts – textbooks, treatment guidelines; the drug of choice for a specific infection is often based on the in vitro activity against the causative organisms, documented clinical efficacy of the agent against the causative organisms, PK properties of the drug (adequate concentration at site of infection), patient characteristics, etc d. Dosage forms available – oral (tablet, capsule, suspension), parenteral (intramuscular, intravenous), intrathecal i. The route of administration depends on the severity of illness of the patient (patient with hypotension should not receive oral therapy due to unreliable drug absorption); the age of the patient (can the patient swallow a tablet?); available dosage forms; etc. ii. Antibiotics that are only available orally should not be used for the treatment of meningitis e. Pharmacokinetics (tissue penetration, route of elimination) - choose an anti-infective that achieves adequate concentrations in the serum and the site of infection (with meningitis – agent must cross the blood brain barrier, etc.).

f. Pharmacodynamics i. What type of activity is required to treat the patient’s infection - bacteriostatic or bactericidal? ii. Consideration should be given to the type of bactericidal activity (concentration-dependent or time-dependent) the antibiotic provides and use this information to select an appropriate dose.

13 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

g. Side effect profiles - the potential adverse events associated with the use of each antibiotic must be carefully considered for each patient i. Nephrotoxic agents should be used with caution (e.g., aminoglycosides, amphotericin) in patients with underlying renal insufficiency. h. Cost – antimicrobial agents are a major portion of hospital drug expenditures, and include more than just the obvious acquisition cost of the drug. Other considerations include the ancillary costs (preparation, storage, distribution, and administration of the drug), cost of frequent dosing, and the costs associated with monitoring and managing toxicity or serious adverse effects.

14 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

APPENDIX A: CLINICALLY-RELEVANT BACTERIA

GRAM-POSITIVE AEROBES GRAM-NEGATIVE AEROBES

Gram-positive cocci in clusters Gram-negative cocci Staphylococcus aureus Moraxella catarrhalis Staphylococcus epidermidis Neisseria meningitidis Staphylococcus saprophyticus Neisseria gonorrhoeae Staphylococcus haemolyticus Gram-negative coccobacilli Staphylococcus hominis Haemophilus influenzae Staphylococcus capitis Haemophilus parainfluenzae Staphylococcus saccharolyticus Gram-negative bacilli Gram-positive cocci in pairs Enterobacteriaceae Streptococcus pneumoniae Citrobacter freundii Gram-positive cocci in chains Enterobacter aerogenes or cloacae Group Streptococcus Escherichia coli Group A Strep - Streptococcus pyogenes Klebsiella pneumoniae Group B Strep - Streptococcus agalactiae Morganella morganii Group C Strep - Streptococcus equi Proteus mirabilis or vulgaris Group D Strep – S bovis, S. equinus Providencia spp Group F, G Strep Salmonella spp. Viridans Streptococcus Shigella spp. Streptococcus mitis Serratia marcescens Streptococcus milleri Yersinia pestis Streptococcus mutans Streptococcus sanguis Non-Enterobacteriaceae Streptococcus salivarius Acinetobacter spp Streptococcus intermedius Aeromonas hydrophila Gram-positive cocci in pairs AND chains Bordetella pertussis Enterococcus faecalis Burkholderia cepacia Enterococcus faecium Campylobacter jejuni Enterococcus gallinarum Gardnerella vaginalis Enterococcus casseliflavus Helicobacter pylori Gram-Positive BACILLI Pasteurella multocida Bacillus anthracis Pseudomonas aeruginosa Bacillus cereus Stenotrophomonas maltophilia Corynebacterium diphtheriae Vibrio cholerae Corynebacterium jeikeium Lactobacillus spp. Listeria monocytogenes Nocardia asteroides Streptomyces spp.

ANAEROBES 15 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

“Above the Diaphragm”

Gram-positive cocci Gram-negative cocci Gram-positive bacilli

Peptococcus Prevotella Actinomyces israelii Peptostreptococcus Veillonella Prevotella Porphyromonas Fusobacterium

“Below the Diaphragm”

Gram-positive bacilli Gram-negative bacilli

Clostridium perfringens Bacteroides fragilis Clostridium difficile Bacteroides fragilis group {“DOT” = distasonis, ovatus, thetaiotamicron) Clostridium tetani Fusobacterium spp. Prevotella

“Skin Anaerobes” Propionibacterium acnes (a gram-positive bacilli)

ATYPICAL BACTERIA Chlamydophila pneumoniae Chlamydia trachomatis Legionella pneumophila Mycoplasma pneumoniae

SPIROCHETES Treponema pallidum (syphilis) Borrelia burgdorferi (Lyme disease) Leptospira interrogans

16 Pharmacology & Therapeutics Introduction to Antibiotics October 15, 2012 Paul O’Keefe, M.D.

APPENDIX B: ANTIBIOTIC CLASS SUMMARY

Class Group/ Name Static or Cidal CELL WALL SYNTHESIS INHIBITORS -Lactams Penicillins Bactericidal Cephalosporins Bactericidal Carbapenems Bactericidal Monobactams (aztreonam) Bactericidal -lactam inhibitor combos (Zosyn, Unasyn) Bactericidal Glycopeptides Vancomycin Bactericidal Lipopeptides* Daptomycin Bactericidal PROTEIN SYNTHESIS INHIBITORS Aminoglycosides* Gentamicin, tobramycin, amikacin Bactericidal Macrolides Erythromycin, azithromycin, clarithromycin Bacteriostatic Tetracyclines, Glycylcyclines Doxycycline, tetracycline, tigecycline Bacteriostatic Chloramphenicol Bacteriostatic Lincosamides Clindamycin Bacteriostatic Streptogramins Quinupristin/ dalfopristin (Synercid) Bacteriostatic Oxazolidinones Linezolid Bacteriostatic NUCLEIC ACID SYNTHESIS INHIBITORS Fluoroquinolones* Ciprofloxacin, levofloxacin, moxifloxacin Bactericidal Metronidazole* Bactericidal METABOLIC INHIBITORS Sulfonamides Trimethoprim-sulfamethoxazole Bactericidal

* Concentration-dependent bactericidal activity

17 S. Erdman/Jan 2011

SPECTRUM OF ACTIVITY SUMMARY CHART

Organism Penicillins Cephalosporins Carba Mono FQs Mac AGs Vanc Syner, Tets¶ Bact Col Clind Metro st £ PenG Naf Amp Una, Tic Pip Tim/ 1 2nd 3rd 4th Anti Imi, Mero Aztreo Cip Levo Ery, Gent, Linez, MRSA Erta, Dori Aug Zos Moxi Cla Tob,, Dapto Azi Amik Telav MSSA X X X X X X‡ X X X X X ?X X X X X X X MRSA X X X X X¶ X PSSP X X X X X X X X‡ X X X ?X X X X X X X PRSP X‡ X X ?X X X X Viridans Strep X X X X X X X X X‡ X X X ?X X X X X X X Group Strep X X X X X X X X X‡ X X X ?X X X X X X X Enterococcus X X X X X X ?X X X X*** E. faecalis (VRE) H. influenzae X§ X X X X X X X X X X X X X∞ X X X M. catarr X X X X X X X X X X∞ X Neisseria X X X X X X X X X X X X X X X E coli X X X X X X X X X X X X X X X X X Proteus X X X X X X X X X X X X X X X X Klebsiella X ?X X X X X X X X X X X X X X Enterobacter X X X X X X X X X X X X X Serratia X X X X X X X X X X X Salmonella X X X X X X X X X X X X X X X Pseudomonas X X X X† X X** X X X€ X X ADA X X X X X X X X ?X BDA X X X X* X ?X X C. difficile X X Legionella X X X X MSSA = Methicillin-Susceptible Staphylococcus aureus ADA = Above the Diaphragm Anaerobes MRSA = Methicillin-Resistant Staphylococcus aureus BDA = Below the Diaphragm Anaerobes, especially Bacteroides spp. PSSP = Penicillin-Susceptible Streptococcus pneumoniae PRSP = Penicillin-Resistant Streptococcus pneumoniae Una = Unasyn (ampicillin/sulbactam), Aug = Augmentin (amoxicillin/clavulanate) Tim/Zos = Timentin (ticarcillin/clavulanate) and Zosyn (piperacillin/tazobactam) § β-lactamase negative strains only ‡ Ceftriaxone and cefotaxime only † Ceftazidime and cefoperazone only * Cephamycin antibiotics including cefotetan and cefoxitin ** Not ertapenem £ Levofloxacin with better activity against gram-negatives €Not moxifloxacin ∞ Azithromycin and clarithromycin only ***Activity versus VRE (Synercid only vs VRE faecium; telavancin only against some VRE) - a TARGET organism ¶ Tigecycline with expanded coverage against gram-positive aerobes, gram-negative aerobes (except Proteus and Pseudomonas) and anaerobes

Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

#28 - PENICILLINS

Date: October 16, 2012, 10:00 – 11:00 AM

Suggested Reading: Wright AJ. The penicillins. Mayo Clinic Proceedings 1999;74:290-307.

Learning Objectives:

Beta-Lactams 1. Explain the differences in the chemical structure between the penicillins, cephalosporins, carbapenems, and monobactams. 2. Describe the general characteristics of -lactam antibiotics including their mechanism of action, mechanisms of resistance, pharmacodynamic properties, elimination half-life, route of elimination, and potential for cross-allergenicity.

Penicillins 1. Describe the differences in the spectrum of activity between the natural penicillins, the penicillinase-resistant penicillins, the aminopenicillins, the carboxypenicillins, the ureidopenicillins, and the -lactamase inhibitor combinations with special emphasis on the specific penicillin agents that have activity against Staphylococcus aureus, Pseudomonas aeruginosa, and Bacteroides fragilis. List examples of commonly used agents within each of the penicillin classes. 2. Describe the distribution characteristics of the penicillins into the cerebrospinal fluid, urinary tract, lungs, skin/soft tissue, and bone. List the penicillins that are not primarily eliminated by the kidneys. List the penicillins that require dosage adjustment in renal insufficiency, and those that are removed by hemodialysis. 3. List the penicillins that should be used with caution in patients with congestive heart failure (CHF) or renal failure due to the sodium load associated with their parenteral formulations. List the parenteral penicillin agent that has the most mEq of sodium per gram. 4. Discuss the main clinical uses of representative penicillins within each group of penicillins. 5. Describe the major adverse effects associated with the penicillin antibiotics. List the penicillins that are most likely to cause interstitial nephritis.

Drugs Covered in this Lecture:

Natural Penicillins: Aqueous Penicillin G, Benzathine Penicillin, Procaine Penicillin G, Penicillin VK Penicillinase-Resistant Penicillins: Nafcillin, Oxacillin, Dicloxacillin Aminopenicillins: Ampicillin, Amoxicillin Carboxypenicillins: Ticarcillin Ureidopenicillins: Piperacillin β-Lactamase Inhibitor Combinations: Ampicillin-Sulbactam (Unasyn), Amoxicillin-Clavulanate (Augmentin Piperacillin-Tazobactam (Zosyn)

1 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

-LACTAMS (Penicillins, Cephalosporins, Carbapenems, Monobactams)

Six General Characteristics of -Lactam Antibiotics (with a few exceptions)

1. Same mechanism of action - inhibitors of cell wall synthesis

2. Same mechanisms of resistance – destruction by β-lactamase enzymes; alteration in penicillin binding proteins (PBPs); decreased permeability of outer cell membrane in gram-negative bacteria

3. Pharmacodynamic properties – time-dependent bactericidal activity (except against Enterococcus spp.)

4. Short elimination half-life (< 2 hours) - repeated, frequent dosing is needed for most agents to maintain serum concentrations above the MIC of the infecting bacteria for an adequate amount of time (except ceftriaxone, cefoperazone, cefotetan, cefixime, ertapenem)

5. Renal elimination – primarily eliminated unchanged by glomerular filtration and tubular secretion (except nafcillin, oxacillin, ceftriaxone, cefoperazone)

6. Cross-allergenicity - all except aztreonam

#51 - PENICILLINS

I. INTRODUCTION

In 1929, penicillin was accidentally discovered by Dr. Alexander Fleming when he noted the antibacterial activity of a mold, Penicillium notatum, that was contaminating bacterial culture plates in his laboratory. Due to difficulties with purification and production, penicillin was not used in the treatment of infections until 1941 when it was utilized in the treatment of staphylococcal and streptococcal infections in seriously ill patients. Throughout the years, natural penicillin has remained a useful antibiotic for some of the bacteria for which it was initially introduced. The emergence of bacteria resistant to natural penicillin, as well as the need for agents with expanded antibacterial activity, led to the development of several groups of semisynthetic penicillins with varying side chains to enhance antibacterial activity and improve pharmacologic activity.

II. CHEMISTRY

A. All penicillins share the basic structure of a 5-membered thiazolidine ring connected to a - lactam ring, with attached acyl side chains.

B. Manipulations of the side chain have led to agents with differing antibacterial spectrums, greater -lactamase stability, and pharmacokinetic properties.

C. Bacterial -lactamase enzymes may hydrolytically attack the -lactam ring and render the penicillin inactive.

2 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

A = thiazolidine ring, B = β-lactam ring, C = acyl side chain

III. MECHANISM OF ACTION

A. Penicillins interfere with bacterial cell wall synthesis by binding to and inhibiting enzymes called penicillin-binding proteins (PBPs) that are located in the cell wall of bacteria.

B. PBPs are enzymes (transpeptidases, carboxypeptidases, and endopeptidases) that regulate the synthesis, assembly, and maintenance of peptidoglycan (cross-linking of the cell wall). The number, type, and location of PBPs vary between bacteria.

C. Inhibition of PBPs by -lactam antibiotics leads to inhibition of the final transpeptidation step of peptidoglycan synthesis, exposing a less osmotically stable cell membrane that leads to decreased bacterial growth, bacterial cell lysis, and death.

D. Penicillins, like all -lactam antibiotics, are bactericidal, except against Enterococcus spp. where they display bacteriostatic activity.

IV. MECHANISMS OF RESISTANCE

A. There are 3 primary mechanisms of resistance to penicillin antibiotics

1. Production of -lactamase enzymes

a. The most important and most common mechanism of bacterial resistance where the bacteria produces a -lactamase enzyme that hydrolyzes the cyclic amide bond of the -lactam ring, inactivating the antibiotic.

b. Over 100 different -lactamase enzymes have been identified. -lactamase enzymes may be plasmid-mediated or chromosomally-mediated, constitutive or inducible.

c. Produced by many gram-negative (H. influenzae, N. gonorrhoeae, M. catarrhalis, K. pneumoniae, E. coli, Proteus spp., P. aeruginosa, S. marcescens, etc.), some gram-positive (Staphylococcus aureus), and some anaerobic (Bacteroides fragilis) bacteria.

3 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

i. -lactamase enzymes produced by gram-negative bacteria reside in the periplasmic space (very efficient).

d. -lactamase inhibitors have been developed and combined with some penicillin agents to prevent the -lactamase enzymes of some bacteria from hydrolyzing the penicillin.

2. Alteration in the structure of the PBPs, which leads to decreased binding affinity of penicillins to the PBPs (e.g., methicillin-resistant Staphylococcus aureus, penicillin- resistant Streptococcus pneumoniae).

3. Inability of the antibiotic to reach the PBP target due to poor penetration through the outer membrane of the bacteria (gram-negative).

V. CLASSIFICATION AND SPECTRUM OF ACTIVITY

A. There are several groups of natural and semisynthetic penicillins currently available that have different spectrums of antibacterial activity. The different groups of semisynthetic penicillins were developed to provide extended antibacterial activity, including coverage against bacteria resistant to previous groups of penicillins.

B. Natural Penicillins - The first agents in the penicillin class to be used clinically. Examples of natural penicillins include aqueous penicillin G, benzathine penicillin G, procaine penicillin G, penicillin VK.

1. Gram-Positive: excellent activity against non--lactamase-producing gram- positive cocci and bacilli  Group Streptococci (groups A, B, C, F, G)  Viridans streptococci  Some Enterococcus spp.  Some Streptococcus pneumoniae (high level resistance ~ 15 to 20%)  Very little activity against Staphylococcus spp.- due to penicillinase production  Bacillus spp. (including B. anthracis)  Corynebacterium spp.

2. Gram-Negative: only against some gram-negative cocci  Neisseria meningitidis, non--lactamase-producing Neisseria gonorrhoeae, Pasteurella multocida

3. Anaerobes: good activity against gram-positive anaerobes  Mouth anaerobes (gram-positive cocci, “above the diaphragm”) – such as Peptococcus spp, Peptostreptococcus spp.  Clostridium spp. (gram-positive bacilli, “below the diaphragm”), with the exception of C. difficile

4 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

4. Other  Treponema pallidum, Actinomyces spp.

Penicillin G is still considered to be a DRUG OF CHOICE for the treatment of infections due to Treponema pallidum (syphilis), Neisseria meningitidis, Corynebacterium diphtheriae, Bacillus anthracis (anthrax), Clostridium perfringens and tetani, viridans and Group Streptococci.

C. Penicillinase-Resistant Penicillins - Developed to address the emergence of penicillinase-producing staphylococci that rendered the natural penicillins inactive. They contain an acyl side chain that sterically inhibits the action of penicillinase by preventing opening of the -lactam ring. Examples include nafcillin, methicillin, oxacillin, cloxacillin, and dicloxacillin.

1. Gram-Positive  Methicillin Susceptible Staphylococcus aureus (MSSA) - NOT ACTIVE AGAINST MRSA  Viridans and Group streptococci (less activity than Pen G)  No activity against Enterococcus spp. or S. pneumoniae

2. Gram-Negative: no activity

3. Anaerobes: limited

D. Aminopenicillins - Developed to address the need for penicillins with extended activity against gram-negative aerobic bacilli. Aminopenicillins were formulated by the addition of an amino group to the basic penicillin molecule. Examples include ampicillin and amoxicillin.

1. Gram-Positive: similar activity to the natural penicillins (also ineffective against Staphylococcus aureus because destroyed by penicillinase)  Better activity than natural penicillin against Enterococcus spp.  Excellent against Listeria monocytogenes, a gram-positive bacillus

2. Gram-Negative: better activity than natural penicillins  H. influenzae (only -lactamase negative strains  70%)  E.coli (45 to 50% of strains are resistant)  Proteus mirabilis  Salmonella spp., Shigella spp.

3. Anaerobes: activity similar to Pen G

Drug of Choice for infections due to Listeria monocytogenes, Enterococcus

5 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

E. Carboxypenicillins – Developed to address the emergence of more resistant gram-negative bacteria and the increasing frequency of Pseudomonas aeruginosa as a nosocomial pathogen. These agents were formulated by adding a carboxyl group to the basic penicillin molecule. Examples include carbenicillin and ticarcillin.

1. Gram-Positive: generally weak activity  Less active against Streptococcus spp.  Not active against. Enterococcus or Staphylococcus spp.

2. Gram-Negative: enhanced activity  Same gram-negative bacteria as aminopenicillins (including indole-positive Proteus mirabilis)  Enterobacter spp.  Providencia spp.  Morganella spp.  Pseudomonas aeruginosa

** NOT active against Klebsiella spp. or Serratia spp.

F. Ureidopenicillins – Developed to further enhance activity against gram-negative bacteria. These agents are derived from the ampicillin molecule with acyl side chain adaptations that allow for greater cell wall penetration and increased PBP affinity. The ureidopenicillins are the most broad-spectrum penicillins available without -lactamase inhibitors. Examples include mezlocillin, azlocillin, and piperacillin.

1. Gram-Positive  Good activity against viridans and Group Streptococci  Some activity against Enterococcus spp.  No activity against Staphylococcus spp.

2. Gram-Negative: improved activity  Displays activity against most Enterobacteriaceae  Active against Klebsiella spp. and Serratia marcescens  Pseudomonas aeruginosa (piperacillin is the most active penicillin)

3. Anaerobes:  Activity similar to Pen G against Clostridium and Peptostreptococcus  Some activity against Bacteroides fragilis

6 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

G. -lactamase Inhibitor Combinations: Available as a combination product containing a penicillin and a -lactamase inhibitor. The -lactamase inhibitor irreversibly binds to the catalytic site of the -lactamase enzyme, preventing the hydrolytic action on the penicillin. The -lactamase inhibitors enhance the antibacterial activity of their companion penicillin in situations where the resistance is primarily the result of -lactamase production. Examples: Amoxicillin / Clavulanic Acid (Augmentin) – PO Ampicillin / Sulbactam (Unasyn) – IV Ticarcillin / Clavulanic Acid (Timentin) – IV Piperacillin / Tazobactam (Zosyn) – IV

1. These combination agents will retain the same activity of the parent penicillin against non -lactamase producing organisms, and will have enhanced activity against -lactamase producing bacteria.

2. Gram-Positive  Provide activity against -lactamase producing strains of Staphylococcus aureus (they have activity against MSSA).

3. Gram-Negative  Enhanced activity against -lactamase producing strains of E. coli, Proteus spp., Klebsiella spp., H. influenzae, M. catarrhalis, and N. gonorrhoeae.  Not very active against the inducible -lactamase enzymes produced by Serratia marcescens, P. aeruginosa, indole-positive Proteus spp., Citrobacter spp., and Enterobacter spp. (SPICE bacteria).

4. Anaerobes  Enhanced activity against -lactamase producing strains of B. fragilis and B. fragilis group (DOT) organisms.

VI. PHARMACOLOGY

A. Pharmacodynamic principles of dosing

1. Penicillins display time-dependent bactericidal activity.

2. The pharmacodynamic parameter that correlates with clinical efficacy of the penicillins is Time above the MIC.

3. PAE for gram-positive bacteria; no significant PAE for gram-negatives.

4. Penicillins are bactericidal, but only display bacteriostatic activity against Enterococcus spp. Bactericidal activity (synergy) can be achieved against Enterococcus spp. by adding an aminoglycoside (gentamicin or streptomycin), which is used in the treatment of Enterococcal endocarditis.

7 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

B. General pharmacologic properties of the penicillins (see PK charts pages 9 and 10)

1. Absorption

a. Many penicillins are degraded by gastric acid and are unsuitable for oral administration, so they must be administered parenterally.

b. Orally-available penicillins are variably absorbed from the gastrointestinal tract (see PK charts). Concentrations achieved with oral dosing are lower than those achieved with parenteral dosing, so oral therapy should only be used for mild to moderate infections. Food typically delays the rate and/or extent of absorption.

c. Special Absorption Considerations i. Natural penicillins – oral pen G is poorly absorbed so that phenoxymethyl penicillin is used orally (pen VK); IM benzathine and procaine penicillin G are formulated to delay absorption resulting in prolonged serum and tissue concentrations ii. Aminopenicillins – amoxicillin displays higher bioavailability than ampicillin; food delays ampicillin absorption iii. Penicillinase-Resistant Penicillins – oral dicloxacillin displays the best bioavailability iv. Extended Spectrum Penicillins – carbenicillin available orally but with low bioavailability (30-40%); used for UTIs only

2. Distribution

a. Penicillins are widely distributed into body tissues and fluids including pleural fluid, synovial fluid, bone, bile, placenta, and pericardial fluid, but do NOT penetrate the eye or prostate. The variation in distribution of various penicillins depends on their molecular configuration and protein binding.

b. Adequate concentrations of penicillins in the cerebrospinal fluid (CSF) are attainable only in the presence of inflamed meninges when high doses of parenteral penicillins are used.

c. Penicillin binding to serum proteins is variable, ranging from 15% for the aminopenicillins to 97% for dicloxacillin. 3. Elimination

a. Most penicillins are eliminated primarily by the kidneys unchanged via glomerular filtration and tubular secretion, and require dosage adjustment in the presence of renal insufficiency. Exceptions include nafcillin and oxacillin, which are eliminated primarily by the liver, and piperacillin which undergoes dual elimination. b. Probenecid blocks the tubular secretion of renally-eliminated penicillins and can increase their serum concentrations.

8 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

c. Most penicillins are removed during hemodialysis or peritoneal dialysis, and require supplemental dosing after a hemodialysis procedure – the exceptions are nafcillin and oxacillin.

d. ALL penicillins have relatively short elimination half-lives (< 2 hours) and require repeated daily dosing (4 to 6 times daily) or continuous infusion to maintain therapeutic serum concentrations.

4. Other Pharmacologic Considerations

a. Sodium Load – several parenterally-administered penicillins (especially the carboxy- and ureidopenicillins) contain sodium in their parenteral preparations, which must be considered in patients with cardiac or renal dysfunction.

 Aqueous Sodium Penicillin G contains 2.0 mEq per 1 million units  Carbenicillin contains 4.7 mEq per gram  Ticarcillin contains 5.2 mEq per gram (also in Timentin)  Piperacillin contains 1.85 mEq per gram (also in Zosyn)

Table: Pharmacokinetic Characteristics of Natural Penicillins, Aminopenicillins, and Penicillinase- Resistant Penicillins

Drug F (%) Protein Half-life Route of Removal Dosing Route of Binding (hours) Excretion by HD Change Admin For RI Penicillin G -- 45-68 0.5 Renal Yes Yes IM, IV Penicillin V 60-73 75-89 0.5 Renal Yes Yes Oral Ampicillin 30-55 15-25 0.7-1.4 Renal Yes Yes Oral, IV, IM Amp/sulb -- 15-25 0.7-1.4 Renal Yes Yes IV Amoxicillin 75-90 17-20 0.7-1.4 Renal Yes Yes Oral Amox/clav 75-90 17-20 0.7-1.4 Renal Yes Yes Oral Dicloxacillin 35-76 95-97 0.3-0.9 Renal, some Minimal No Oral hepatic Nafcillin -- 70-90 0.5-1.5 Hepatic Minimal No IV, IM Oxacillin 30-35 89-94 0.3-0.9 Hepatic Minimal No Oral, IV, IM F = bioavailability HD = hemodialysis RI = renal insufficiency IV = intravenous IM = intramuscular

9 Pharmacology & Therapeutics Penicillins October 16, 2012 Paul O’Keefe, M.D.

Table: Pharmacokinetic Characteristics of Carboxypenicillins and Ureidopenicillins

Drug Sodium Protein Half-life Route of Removal Dosing Route of Content Binding (hours) Excretion by HD Change Admin (mEq/g) For RI Carbenicillin 4.7 50-60 1.1 Renal Yes Yes Oral, IM, IV Ticarcillin 5.2 50-60 1.2 Renal Yes Yes IV Ticar/clav 5.2 50-60 1.2 Renal Yes Yes IV Piperacillin 1.85 15-20 1.0 Renal and Yes Yes IV hepatic Pip/tazo 1.85 15-20 1.0 Renal and Yes Yes IV hepatic HD = hemodialysis RI = renal insufficiency IV = intravenous IM = intramuscular

VII. CLINICAL USES

A. Natural Penicillins

1. Intravenous aqueous penicillin G is often used for serious infections in hospitalized patients due to its rapid effect and high serum concentrations. Lower serum concentrations are achieved with oral penicillin VK so that its use is limited to the treatment of mild to moderate infections such as pharyngitis or prophylaxis in some circumstances.

2. Considered to be a drug of choice for infections due to:

a. S. pneumoniae (IV or IM – for penicillin-susceptible or penicillin-intermediate strains)

b. Other Streptococci, including S. pyogenes (benzathine pen or aqueous pen), viridans streptococci pharyngitis (PO or IM); bacteremia, endocarditis (with an aminoglycoside), meningitis (IV)

c. Neisseria meningitidis - meningitis, meningococcemia (IV)

d. Treponema pallidum – syphilis (benzathine pen or IV pen)

e. Clostridium perfringens or tetani

f. Actinomycosis

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3. Other Uses:

a. Endocarditis prophylaxis in patients with valvular heart disease undergoing dental procedures at high risk for inducing bacteremia

b. Prevention of rheumatic fever

B. Penicillinase-Resistant Penicillins (Antistaphylococcal Penicillins)

1. Because of enhanced activity against S. aureus, these agents are useful for the treatment of infections due to methicillin-susceptible Staphylococcus aureus (MSSA) such as skin and soft tissue infections, septic arthritis, osteomyelitis, bacteremia, endocarditis, etc. Parenteral therapy should be used for moderate to severe infections.

2. Oral dicloxacillin is useful for the treatment of mild to moderate skin and soft tissue infections, and as follow-up therapy after parenteral therapy for the treatment of more serious infections such as osteomyelitis or septic arthritis.

C. Aminopenicillins

1. Because of activity against respiratory tract pathogens, oral ampicillin and amoxicillin are useful for the treatment of mild to moderate pharyngitis, sinusitis, bronchitis, and otitis media.

2. Oral ampicillin or amoxicillin are useful for uncomplicated urinary tract infections due to susceptible organisms.

3. Parenteral ampicillin is used for the treatment of Enterococcal infections (with an aminoglycoside for endocarditis) and Listeria monocytogenes meningitis.

4. Endocarditis prophylaxis in patients with valvular heart disease.

5. Treatment of Salmonella (amoxicillin) and Shigella (ampicillin).

D. Carboxypenicillins and Ureidopenicillins

1. Due to enhanced activity against gram-negative bacteria, these agents are useful for the treatment of serious infections such as bacteremia, pneumonia, complicated urinary tract infection, peritonitis, intraabdominal infections, skin and soft tissue infections, bone and joint infections, and meningitis caused by gram-negative bacteria (hospital- acquired infections). Piperacillin is the most active penicillin for infections due to Pseudomonas aeruginosa.

2. May be used as empiric therapy in immunocompromised patients.

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E. β-Lactamase Inhibitor Combination Products – enhanced activity against -lactamase- producing bacteria

1. Amoxicillin-clavulanate (Augmentin - PO) is useful for the treatment of otitis media, sinusitis, bronchitis, lower respiratory tract infections, and human or animal bites

2. Due to expanded activity against gram-positive and gram-negative bacteria (including anaerobes), the parenteral combination agents are often utilized in the treatment of polymicrobial infections such as intraabdominal infections, gynecological infections, diabetic foot infections, etc.

a. Ampicillin-sulbactam (Unasyn® – IV) is useful for the treatment of mixed aerobic/anaerobic infections (limited gram-negative coverage).

b. Piperacillin-tazobactam (Zosyn® – IV) is useful for the treatment of polymicrobial infections or other infections involving gram-negative bacteria including hospital- acquired pneumonia, bacteremia, complicated urinary tract infections, complicated skin and soft tissue infections, intraabdominal infections, and empiric therapy for febrile neutropenia.

VIII. ADVERSE EFFECTS

A. Hypersensitivity – most frequently occurring side effect (3 to 10%)

1. Less frequent with oral administration, somewhat higher when administered intravenously.

2. Reactions include pruritus, rash (maculopapular, erythematous, or morbilloform), urticaria, angioedema, hypotension, vasodilation, shock, and anaphylaxis.

a. Anaphylaxis is rare, occurring in 0.004-0.015% of patients.

b. Mediated by antibodies produced against penicillin degradation products that become haptens when bound to tissue proteins.

c. Penicillin skin testing – occasionally used to predict hypersensitivity reactions when a history of a hypersensitivity reaction is unclear.

d. Desensitization is possible (oral or parenteral) in some patients.

3. Cross-allergenicity is observed among natural and semisynthetic penicillins due to their common nucleus – patients allergic to one penicillin product should be considered allergic to other members of the penicillin family, and caution should be used with some other -lactams.

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4. Other allergic reactions include drug fever, serum sickness, Stevens-Johnson syndrome, erythema multiforme, toxic epidermal necrolysis, and exfoliative dermatitis

B. Neurologic

1. Direct toxic effect observed primarily in patients who receive large intravenous doses of some penicillins in the presence of concomitant renal dysfunction.

2. Irritability, jerking, confusion, generalized seizures

C. Hematologic

1. β-lactam-specific cytotoxic IgG or IgM antibodies are developed that bind to circulating WBC or platelets; cause cell lysis when antigen (penicillin) encountered by activation of the complement system

2. Leukopenia, neutropenia or thrombocytopenia - especially in patients receiving long- term (> 2 weeks) therapy

D. Gastrointestinal

1. Transient increases in liver enzymes – especially oxacillin, nafcillin, and carbenicillin

2. Nausea, vomiting

3. Diarrhea – especially with amoxicillin-clavulanate

4. Pseudomembranous colitis (Clostridium difficile diarrhea).

E. Interstitial Nephritis

1. Immune-mediated damage to renal tubules (cell-mediated immunity or antigen- antibody reactions) where the penicillin acts as a hapten when bound to renal tubular cells - most commonly associated with methicillin, but can occur with nafcillin and other penicillins.

2. Initial manifestations may be fever, eosinophilia, pyuria, eosinophiluria, and an abrupt increase in serum creatinine.

3. May progress to renal failure

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F. Other adverse effects include phlebitis (nafcillin); pain and induration with IM injection (benzathine penicillin, penicillin G, ampicillin); hypokalemia (carbenicillin and ticarcillin because they act as nonreabsorbable anions resulting in increased excretion of potassium); sodium overload and fluid retention (ticarcillin, piperacillin)

IX. DOSING

From: Basic and Clinical Pharmacology, 10th edition, 2007, page 732

14 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

CEPHALOSPORINS Original Handout written by S. Erdman, Pharm.D. presented by J. Lentino, M.D.

I. INTRODUCTION

Cephalosporins are semisynthetic -lactam antibiotics that are structurally and pharmacologically related to the penicillins. The first source of cephalosporins, a fungus named Cephalosporium acremonium, was isolated in 1948. The crude filtrates from this fungus were found to inhibit the in vitro growth of Staphylococcus aureus, as well as treat staphylococcal infections and typhoid fever in humans.

II. CHEMISTRY

A. Cephalosporins contain a -lactam ring where the 5-membered thiazolidine ring of the penicillins is replaced by a 6-membered dihydrothiazine ring. This structural difference provides stability against many -lactamase enzymes that render the penicillins inactive.

B. Structural modifications at position 7 of the -lactam ring are associated with changes in antibacterial activity, while changes at position 3 of the dihydrothiazine ring are associated with changes in the pharmacokinetic properties of the cephalosporins.

C. Cephamycins are cephalosporins with a methoxy group at position 7 of the -lactam ring (confers activity against anaerobes such as Bacteroides spp.).

A = dihydrothiazine ring, B = β-lactam ring, R = acyl side chain

III. MECHANISM OF ACTION

A. Cephalosporins, like penicillins, interfere with cell wall synthesis by binding to and inhibiting enzymes called penicillin-binding proteins (PBPs) that are located in the cell wall of bacteria.

1 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

B. PBPs include transpeptidases, carboxypeptidases, and endopeptidases that are responsible for peptidoglycan cross-linking. The number, type and location of PBPs vary between bacteria.

C. Inhibition of PBPs by -lactam antibiotics leads to inhibition of the final transpeptidation step of peptidoglycan synthesis, exposing a less osmotically stable cell wall that leads to decreased bacterial growth, bacterial cell lysis, and death.

D. Cephalosporins, like all -lactam antibiotics, are bactericidal.

IV. MECHANISMS OF RESISTANCE

A. There are 3 primary mechanisms of resistance to cephalosporins

1. Production of -lactamase enzymes

a. The most important and most common mechanism of bacterial resistance where the bacteria produces a -lactamase enzyme that hydrolyzes the cyclic amide bond of the -lactam ring, inactivating the antibiotic.

b. Over 100 different -lactamase enzymes have been identified. - lactamase enzymes may be plasmid-mediated or chromosomally- mediated, constitutive or inducible.

c. Produced by many gram-negative (H. influenzae, N. gonorrhoeae, M. catarrhalis, K. pneumoniae, E. coli, Proteus spp., P. aeruginosa, S. marcescens, etc.), some gram-positive (Staphylococcus aureus), and some anaerobic (Bacteroides fragilis) bacteria.

d. Cephalosporins have variable susceptibility to -lactamases; 3rd and 4th generation cephalosporins are the most resistant to hydrolysis by - lactamase enzymes produced by gram-negative aerobic bacteria.

e. Some bacteria (SPICE) have the ability to produce -lactamase enzymes when exposed to antibiotics that induce their production – these are called inducible -lactamases (such as during treatment of Enterobacter spp. infections with ceftazidime).

2. Alterations in PBPs that lead to decreased binding affinity of cephalosporins to PBPs (e.g., methicillin-resistant S. aureus, penicillin-resistant S. pneumoniae).

3. Inability of the antibiotic to reach the PBP target due to poor penetration through the outer membrane (gram-negative bacteria).

2 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

V. CLASSIFICATION AND SPECTRUM OF ACTIVITY

A. Currently-available cephalosporins are divided into 4 major groups, called “generations”, based primarily on their antimicrobial activity and stability against - lactamase enzymes.

B. In general, 1st generation cephalosporins are best for gram-positive aerobes with activity against a limited number of gram-negative aerobes. As you move down the generations to 2nd and 3rd, gram-positive activity decreases with an increase in activity against gram-negative aerobes. Fourth generation cephalosporins are active against gram-positive and gram-negative aerobes. Also see greater stability against -lactamase enzymes as you move through the generations.

1. First Generation Cephalosporins

a. Excellent activity against gram-positive aerobes - the best activity of all cephalosporins

Methicillin-susceptible Staphylococcus aureus (MSSA) Penicillin-susceptible Streptococcus pneumoniae Group A (S. pyogenes) and Group B streptococci (S. agalactiae) Viridans streptococci

b. Also have activity against a limited number of gram-negative aerobes (PEK):

Proteus mirabilis Escherichia coli Klebsiella pneumoniae

c. Examples of 1st generation cephalosporins (*most often used)

Generic Name Brand Name Route of Administration cefazolin* Ancef, Kefzol intravenous cephalothin Keflin, Seffin intravenous cephradine Velosef, Anspor intravenous, oral cephapirin Cefadyl intravenous cephalexin* Keflex, Keftab, Biocef oral cefadroxil Duricef, Ultracef oral

2. Second Generation Cephalosporins (includes cephamycins and carbacephems)

a. Differences exist in the spectrum of activity among 2nd generation agents because of their structural variability.

3 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

b. In general, are slightly less active than 1st generation agents against gram- positive aerobes such as staphylococci and streptococci (MICs are higher), but are more active against gram-negative aerobes, and for some 2nd generation agents (cephamycins), anaerobes.

c. Gram-positive aerobes - 2nd generation agents have activity against the same bacteria as 1st generation agents, with MICs similar to or slightly higher than 1st generation agents. Cefprozil and cefuroxime have the best gram-positive coverage; cefoxitin and cefotetan have the worst.

d. Gram-negative aerobes - display activity against P. mirabilis, E. coli, and K. pneumoniae like the 1st generation cephalosporins, but they have expanded coverage including:

Haemophilus influenzae Moraxella catarrhalis Neisseria spp.

In addition, may be active against some strains of Citrobacter and Enterobacter that are resistant to 1st generation agents (HENPEK).

e. Anaerobes - only cefoxitin, cefotetan and cefmetazole (the cephamycins) are active against anaerobes including Bacteroides fragilis (cefoxitin is the best).

f. Examples of 2nd generation cephalosporins (* most common)

Generic Name Brand Name Route of Administration cefuroxime* Kefurox, Zenacef intravenous and oral cefamandole Mandol intravenous cefonicid Monocid intravenous cefaclor Ceclor oral cefprozil* Cefzil oral Carbacephems loracarbef Lorabid  oral Cephamycins cefoxitin* Mefoxin intravenous cefotetan Cefotan intravenous cefmetazole Zefazone intravenous

3. Third Generation Cephalosporins

a. In general, are less active than 1st or 2nd generation agents against gram-positive aerobes, but have enhanced activity against gram- negative aerobes.

4 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

b. Gram-positive aerobes - ceftriaxone and cefotaxime have the best activity (among the only cephalosporins that have activity against penicillin-resistant S. pneumoniae), which is thought to be less than 1st or 2nd generation agents; other 3rd generation cephalosporins have relatively poor activity. c. Gram-negative aerobes - expanded spectrum of activity than the 2nd generation agents (HENPECKSSS and more) including:

P. mirabilis, E. coli, K. pneumoniae (better than 1st and 2nd generation agents) H. influenzae, M. catarrhalis, Neisseria gonorrhoeae (even - lactamase producing strains) Neisseria meningitidis Citrobacter spp., Enterobacter spp. (less with oral agents) Morganella spp., Providencia spp., Serratia marcescens Salmonella spp., Shigella spp. Pseudomonas aeruginosa - only ceftazidime and cefoperazone

d. Anaerobes - very limited activity (ceftizoxime has marginal activity)

e. Select 3rd generation cephalosporins (especially ceftazidime) are strong inducers of extended spectrum -lactamases (type 1 or Class C) in gram-negative aerobic bacteria (Enterobacter spp)

f. Examples of 3rd generation cephalosporins (* most commonly used)

Generic Name Brand Name Route of Administration cefotaxime Claforan intravenous ceftriaxone* Rocephin intravenous ceftazidime* Fortaz, Tazidime, Tazicef intravenous cefoperazone Cefobid intravenous ceftizoxime Cefizox intravenous moxalactam no longer commercially available cefixime Suprax oral cefpodoxime* Vantin oral ceftibuten Cedax oral cefdinir Omnicef oral

4. Fourth generation cephalosporins

a. Considered a 4th generation cephalosporin for 2 reasons

i. Extended spectrum of activity, including many gram-positive and gram-negative aerobes (NOT anaerobes)

5 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

Gram-positive aerobes: coverage against staphylococci and streptococci similar to ceftriaxone and cefotaxime

Gram-negative aerobes: displays similar coverage against gram- negative aerobes as 3rd generation agents, including:

Pseudomonas aeruginosa -lactamase producing Enterobacter and E. coli

ii. Excellent stability against -lactamase hydrolysis; is a relatively poor inducer of extended spectrum -lactamases (type 1 or Class C) in gram-negative aerobic bacteria.

b. 4th generation cephalosporin example

Generic Name Brand Name Route of Administration cefepime* Maxipime intravenous

C. Overall, cephalosporins are not active against methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci, Enterococcus spp., Listeria monocytogenes, Legionella pneumophila, Clostridium difficile, Stenotrophomonas maltophilia, and Campylobacter jejuni.

VI. PHARMACOLOGY (see Table on page 9)

A. General pharmacologic properties of cephalosporins

1. Orally-available cephalosporins are well absorbed from the gastrointestinal tract; however, serum concentrations are lower than those achieved with parenteral dosing. The influence of food on the absorption of individual agents is listed in the pharmacokinetic table.

2. Most cephalosporins are widely distributed into tissues and fluids including pleural fluid, synovial fluid, bone, bile, placenta, pericardial fluid and aqueous humor. Adequate concentrations in the cerebrospinal fluid (CSF) are NOT obtained with 1st and most 2nd generation cephalosporins. Therapeutic concentrations of parenteral cefuroxime, parenteral 3rd, and 4th generation cephalosporins are attained in the CSF, especially in the presence of inflamed meninges.

3. Most cephalosporins are eliminated unchanged by the kidneys via glomerular filtration and tubular secretion, and require dosage adjustment in the presence of renal insufficiency. The exceptions include ceftriaxone and cefoperazone, which are eliminated by the biliary system and the liver, respectively. Most

6 Pharmacology and Therapeutics Cephalosporins, Carbapenems, and Monobactams October 17, 2012 Paul O’Keefe, MD

cephalosporins are removed during hemodialysis and require supplemental dosing after a hemodialysis procedure, with the exception of ceftriaxone.

4. Most cephalosporins have relatively short elimination half-lives (< 2 hours), and require repeated daily dosing (3 to 4 times daily) to maintain therapeutic serum concentrations. Exceptions include ceftriaxone (8 hours), cefonicid (4.5 hours), cefotetan (3.5 hours), and cefixime (3.7 hours).

B. Dosing guidelines for the cephalosporins in the presence of normal renal and hepatic function

Antibiotic and Route of Administration Adult Dosage Pediatric Dosage 1st generation cefazolin (IV) 1 - 2 grams every 8 hours 25 - 100 mg/kg/day in 3 to 4 divided doses cephalothin (IV) 1 - 2 grams every 4 hours 60 - 100 mg/kg/day in 4 to 6 divided doses cephalexin (PO) 250 - 500 mg every 6 hours 25 - 50 mg/kg/day in 4 divided doses cefadroxil (PO) 500 - 1,000 mg twice daily 30 mg/kg/day in 2 divided doses

2nd generation cefuroxime (IV) 0.75 - 1.5 g every 8 hours 75 - 100 mg/kg/day in 3 divided doses given every 8 hours cefoxitin (IV) 2 g every 6 hours 80 - 160 mg/kg/day in 4 to 6 divided doses cefotetan (IV) 1 to 2 grams every 12 hours 40 - 60 mg/kg/day in 2 divided doses cefuroxime (PO) 250 - 500 mg twice daily 125 - 250 mg twice daily cefprozil (PO) 250 - 500 mg twice daily 15 mg/kg twice daily

3rd generation cefotaxime (IV) 1 - 2 g every 6 to 8 hours 50 - 180 mg/kg/day in 4 divided doses ceftriaxone (IV) 1 - 2 g every 12-24 hours 50 - 100 mg/kg/day divided every 12 hours (max 4 g/day) ceftazidime (IV) 1 - 2 g every 8 hours 90 - 150 mg/kg/day in 3 divided doses cefixime (PO) 400 mg once daily 8 mg/kg/day once daily cefpodoxime (PO) 100 - 400 mg every 12 hours 10 mg/kg/day divided every 12 hours ceftibuten (PO) 400 mg once daily 9 mg/kg once daily cefdinir (PO) 300mg twice daily 7 mg/kg twice daily

4th generation cefepime (IV) 0.5 - 2 g every 8 to 12 hours up to 50 mg/kg every 8 hours has been used, not approved

7 Cephalosporins Joseph R.Lentino,M.D. ,Ph.D.

CEPHALOSPORIN PHARMACOKINETIC TABLE

PEAK SERUM ROUTE OF EFFECT OF FOOD SERUM GENERIC NAME CONC (g/ml) CSF CONC (g/ml) ELIMINATION HALF-LIFE hrs ON PEAK CONC PROT BIND %

1st generation

Cefazolin - IV 80 (1 g) Renal 1.8 80 Cephalothin - IV 30 (1 g) Renal 0.6 71 Cephalexin - PO 18 (0.5 g) Renal 0.9 None 10 Cefadroxil - PO 16 (0.5 g) Renal 1.2 None 20 Cephradine - PO 10 (0.5 g) Renal 0.7 None 10

2nd generation

Cefamandole - IV 150 (2 g) Renal 0.8 75 Cefonicid - IV 260 (2 g) Renal 4.5 98 Cefuroxime - IV 100 (1.5 g) 1.1 - 17 Renal 1.3 35 Cefoxitin - IV 150 (2 g) Renal 0.8 70 Cefotetan - IV 230 (2 g) Renal 3.5 90 cefuroxime axetil - PO 8 - 9 (0.5 g) Renal 1.3 Increased 35 Cefaclor - PO 13 (0.5 g) Renal 0.8 Decreased 25 Cefprozil - PO 10 (0.5 g) Renal 1.2 None 42 Loracarbef - PO 15 (0.4 g) Renal 1.1 Decreased 35

3rd generation

Cefotaxime - IV 130 (2 g) 5.6 - 44 Renal 1.0 35 Ceftriaxone - IV 250 (2 g) 1.2 - 39 Biliary/renal 8.0 83 - 96 Ceftizoxime - IV 130 (2 g) 0.5 - 29 Renal 1.7 30 Cefoperazone - IV 250 (2 g) Hepatic 2.0 87 - 93 Ceftazidime - IV 160 (2 g) 0.5 - 30 Renal 1.8 17 Cefixime - PO 3.9 (0.4 g) Renal 3.7 None 67 Cefpodoxime axetil - PO 4 (0.4 g) Renal 2.2 Increased 40 Ceftibuten - PO 11 (0.2 g) Renal 2.5 None 63 Cefdinir - PO 2.87 (0.6 g) Renal 1.8 None 60 - 70

4th generation

Cefepime - IV 150 (2 g) yes, unknown Renal 2.1 20 cefpirome 100 (1 g) 1.3 - 7.5 Renal 2.0 10

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

VII. CLINICAL USES

A. First generation cephalosporins

1. Orally-administered 1st generation cephalosporins achieve lower serum concentrations than parenteral agents and should only be used for the treatment of mild to moderate skin infections or uncomplicated urinary tract infections.

2. Treatment of skin and soft tissue infections, septic arthritis, osteomyelitis, and endocarditis due to MSSA and streptococci.

3. Cefazolin is the drug of choice for surgical prophylaxis against surgical site infections for many surgical procedures because of its activity against staphylococci; can usually be administered as a single preoperative dose.

4. First generation cephalosporins have coverage against a few gram-negative aerobes and can be used for the treatment of urinary tract infections (oral or intravenous) or bacteremias (intravenous) due to susceptible organisms (PEK).

5. First generation cephalosporins do not penetrate the central nervous system, and should NOT be used for meningitis.

B. Second generation cephalosporins

1. Due to their activity against gram-positives and expanded spectrum of activity against gram-negative bacteria including H. influenzae and M. catarrhalis, oral 2nd generation agents, such as cefuroxime, are useful for the treatment of pharyngitis, tonsillitis, sinusitis, otitis media, bronchitis and mild to moderate community-acquired pneumonia.

2. Oral 2nd generation cephalosporins are also useful for the treatment of mild to moderate skin and soft tissue infections, and uncomplicated urinary tract infections due to susceptible bacteria.

3. Although cefuroxime does penetrate the central nervous system, adequate CSF bactericidal activity is not routinely achieved so that it is no longer recommended for the treatment of meningitis.

4. The cephamycins, cefoxitin, cefotetan, and cefmetazole, have activity against gram-negative aerobes and anaerobes, including Bacteroides fragilis, so they are useful for prophylaxis in abdominal surgical procedures and for the treatment of polymicrobial infections such as intraabdominal infections (diverticulitis, appendicitis, bowel perforation), pelvic infections (pelvic inflammatory disease), and skin and soft tissue infections in patients with diabetes.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

C. Third generation cephalosporins

1. Due to expanded activity against gram-negative aerobes, 3rd generation cephalosporins are used for the treatment of bacteremia, pneumonia, complicated urinary tract infection, peritonitis, intraabdominal infections, skin and soft tissue infections, bone and joint infections, and meningitis (those that penetrate the CSF) caused by gram-negative bacteria (nosocomial infections). If Pseudomonas aeruginosa is known or suspected, ceftazidime or cefoperazone should be used. If anaerobes are known or suspected, metronidazole or clindamycin should be added.

2. Ceftriaxone is used as a single IM dose for uncomplicated gonorrhea.

3. Cefotaxime and ceftriaxone have good activity against gram-positive aerobes, and may be used for the treatment of infections due to penicillin- resistant Streptococcus pneumoniae (meningitis, pneumonia). Ceftriaxone can be used for the treatment of viridans strep endocarditis in clinically stable patients as outpatient parenteral therapy.

4. Oral third generation cephalosporins are used for the treatment of uncomplicated urinary tract infections, acute otitis media, minor soft tissue infections, and acute sinusitis.

D. Fourth generation cephalosporins

1. Cefepime is used for the treatment of community- and hospital-acquired pneumonia, bacteremia, uncomplicated and complicated urinary tract infections, skin and soft tissue infections, intraabdominal infections gram- negative meningitis, and empiric therapy for febrile neutropenia. Cefepime also has antipseudomonal activity. If anaerobes are known or suspected, metronidazole or clindamycin should be added.

VIII. ADVERSE EFFECTS

A. Hypersensitivity - 5%

1. Reactions include pruritus, rash (maculopapular, erythematous, or morbilliform), urticaria, angioedema, hypotension, vasodilation, shock, and anaphylaxis.

2. Hypersensitivity reactions to cephalosporins occur most frequently in patients with a history of penicillin allergy. The degree of cross-reactivity is 5 to 15%, and clinicians must consider the allergic reaction to penicillin (? IgE mediated) and the degree of cross-reactivity when deciding if a cephalosporin should be used in a patient with a history of allergy to penicillin.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

a. Immediate or accelerated hypersensitivity reactions (anaphylaxis, laryngeal edema, hives, bronchospasm) – avoid other cross-reactive - lactams, such as cephalosporins.

b. Delayed hypersensitivity reactions (rash, pruritus) – give other - lactams with caution keeping in mind the degree of cross-reactivity.

3. Other skin reactions include Stevens-Johnson syndrome, erythema multiforme, toxic epidermal necrolysis, and exfoliative dermatitis.

B. Some cephalosporins have a 5-NMTT side chain (nitromethylthiotetrazole) that confers unique adverse effects.

1. Cephalosporins with the NMTT side chain include cefamandole, cefotetan, cefmetazole, cefoperazone, and moxalactam.

2. Hypoprothrombinemia with or without bleeding due to blocking of enzyme in vitamin K metabolism or reduction of vitamin K producing bacteria in the GI tract. Moxalactam also reduces platelet aggregation that significantly increased the incidence of bleeding.

3. Disulfiram reaction (ethanol intolerance).

C. Hematologic

1. β-lactam-specific cytotoxic IgG or IgM antibodies are developed that bind to circulating WBC or platelets; cause cell lysis when antigen (penicillin) encountered by activation of the complement system

2. Leukopenia, neutropenia or thrombocytopenia - especially in patients receiving long-term (> 2 weeks) therapy

D. Gastrointestinal

1. Transient increases in liver enzymes.

2. Biliary sludging – with ceftriaxone therapy.

3. Nausea, vomiting.

4. Pseudomembranous colitis (Clostridium difficile diarrhea). Some cephalosporins may cause diarrhea that is not due to C. difficile.

E. Precipitation of ceftriaxone with IV calcium products – avoid coadministration.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

F. Other adverse effects include phlebitis; drug fever; interstitial nephritis (rare); neurotoxicity; nonconvulsive status epilepticus (cefepime, ceftazidime).

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

CARBAPENEMS

I. INTRODUCTION

The carbapenem antibiotics, -lactam antibiotics with a carbapenem nucleus, were initially discovered in the mid-1970s. The clinical development of the carbapenems was delayed due to chemical instability and toxicity (nephrotoxicity and neurotoxicity) associated with earlier compounds in this class. Currently, four carbapenem antibiotics are commercially available in the United States: imipenem, the first carbapenem antibiotic, received FDA approval in 1986, meropenem received FDA approval in 1996, ertapenem received FDA approval in 2001, and doripenem received FDA approval in 2007.

II. CHEMISTRY

A. Carbapenems are -lactam antibiotics that contain a -lactam ring fused to a 5- membered ring, like the penicillins. However, the 5-membered ring of the carbapenems contains a carbon atom at position one (hence the name, carbapenem) instead of a sulfur atom, and the addition of a double bond.

B. All carbapenems contain a hydroxyethyl group in the trans configuration at position 6 as compared to an acylamino group in the cis configuration of the penicillins and cephalosporins. This structural difference results in increased antibacterial activity and greater stability against most -lactamase enzymes.

B = β-lactam ring

III. MECHANISM OF ACTION

A. Like other -lactam antibiotics, carbapenem antibiotics display time-dependent bactericidal activity (except against Enterococcus), and cause bacterial cell death by covalently binding to PBPs that are involved in the biosynthesis of bacterial cell walls.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

B. Each carbapenem displays different affinities for specific PBPs, which appear to be genus-specific. The highest binding affinity for imipenem, meropenem and doripenem is PBP-2. C. The carbapenems are zwitterions that are relatively small, which enable them to penetrate the outer membrane of most gram-negative bacteria and gain access to the PBPs more readily than many other -lactam antibiotics.

IV. MECHANISMS OF RESISTANCE

A. Decreased permeability as a result of alterations to outer membrane porin proteins is an important mechanism of resistance in gram-negative bacteria, particularly Pseudomonas aeruginosa.

B. Hydrolysis of carbapenem antibiotics by -lactamase or carbapenemase enzymes. However, all of the carbapenems display intrinsic resistance to nearly all -lactamases (are very stable and not destroyed), including both plasmid- and chromosomally- mediated enzymes.

C. Alterations in PBPs that lead to decreased binding affinity of the carbapenem.

V. SPECTRUM OF ACTIVITY

A. The carbapenems are currently the most broad-spectrum antibiotics, with good activity against many gram positive AND gram-negative aerobes AND anaerobes.

B. Gram-positive aerobes - imipenem and doripenem exhibit good activity; meropenem and ertapenem are generally 2 to 4 times less active than imipenem methicillin-susceptible Staphylococcus aureus (MSSA) penicillin-susceptible Streptococcus pneumoniae Groups A, B, and C streptococci viridans streptococci Enterococcus faecalis only (most strains of E. faecium are resistant)

C. Gram-negative aerobes – the carbapenems display excellent activity against many gram-negative aerobes (doripenem and meropenem are the best, followed by imipenem and ertapenem); differences in susceptibility exist between the agents and are species-dependent; carbapenems display activity against -lactamase producing strains that display resistance to other -lactam antibiotics

E. coli Citrobacter freundii Klebsiella spp. Enterobacter spp. Serratia marcescens Proteus spp. Morganella morganii Providencia spp. Yersinia spp. Acinetobacter spp. (not ertapenem)

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

Neisseria spp. Haemophilus influenzae Moraxella catarrhalis Campylobacter jejuni Salmonella spp. Shigella spp. Pseudomonas aeruginosa (NOT ertapenem) D. Anaerobes – all carbapenems display excellent activity against clinically significant gram-positive and gram-negative anaerobes including:

Gram-positive anaerobes Peptostreptococcus sp. Peptococcus spp. Clostridium perfringens and tetani

Gram-negative anaerobes Bacteroides fragilis Bacteroides vulgatus Bacteroides distasonis Bacteroides thetaiotamicron Bacteroides ovatus Prevotella bivia Fusobacterium spp. Veillonella parvula

E. The carbapenems do NOT have activity against methicillin-resistant Staphylococcus aureus (MRSA), coagulase-negative staphylococci, some enterococci, Clostridium difficile, Stenotrophomonas maltophilia, Nocardia, and atypical bacteria.

VI. PHARMACOLOGY – no oral agents at this time

A. Distribution – all carbapenems are widely distributed in various body tissues and fluids including saliva, sputum, aqueous humor, skin, soft tissue, bone, bile, endometrium, heart valves, placenta; pleural, peritoneal, and wound fluids.

1. CSF penetration - only low concentrations of imipenem diffuse into the CSF following IV administration, with CSF concentrations approximately 1 to 10% of concurrent serum concentrations; meropenem penetrates into the CSF better than imipenem and ertapenem, with CSF concentrations up to 52% of simultaneous serum concentrations in patients with inflamed meninges

B. Elimination

1. The major route of elimination of all of the carbapenems is urinary excretion of unchanged drug involving both glomerular filtration and tubular secretion.

a. Imipenem undergoes hydrolysis in the kidney by an enzyme called dihydropeptidase (DHP) to microbiologically inactive and potentially nephrotoxic metabolites. A DHP inhibitor called cilastatin is added to commercially-available preparations of imipenem to prevent renal metabolism and protect against potential nephrotoxicity.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

2. The elimination half-life of imipenem, meropenem and doripenem is approximately 1 hour in patients with normal renal function; the elimination half-life of ertapenem is approximately 4 hours.

3. All carbapenems require dosage adjustment in patients with renal dysfunction and are removed during hemodialysis procedures so they are usually dosed after hemodialysis.

C. Dosing of the carbapenems in patients with normal renal function

Adult Dosage Pediatric Dosage

IMIPENEM 250 mg to 500 mg IV every 6 hours 15 to 25 mg/kg IV every 6 hours (usual dose 500 mg IV every 6 hours) (not recommended)

MEROPENEM 1 to 2 grams IV every 8 hours 20 to 40 mg/kg IV every 8 hours

ERTAPENEM 1 gram IV every 24 hours

DORIPENEM 500 mg IV every 8 hours

VII. CLINICAL USES - are very expensive

A. The carbapenems are very broad-spectrum antibiotics that are typically used for polymicrobial infections where they can be used as monotherapy such as intraabdominal infections or skin and skin structure infections in diabetic patients. Ertapenem does not have activity against Pseudomonas aeruginosa.

B. Empiric therapy for nosocomial infections such as serious lower respiratory tract infections, septicemia, and complicated urinary tract infections, while waiting for the results of culture and susceptibility data. Ertapenem does not have activity against Pseudomonas aeruginosa. Once results of the cultures and susceptibilities are known, therapy is often changed to a less broad spectrum and less costly (and more targeted) antimicrobial agent.

C. Infections due to resistant bacteria, especially those organisms that produce type 1 or class C β-lactamase enzymes.

D. Febrile neutropenia – imipenem or meropenem

E. Meningitis (children) - meropenem

VIII. ADVERSE EFFECTS

A. Hypersensitivity - 3%

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

1. Reactions include rash, fever, pruritus, urticaria, angioedema, hypotension and anaphylaxis.

2. Cross reactivity (5 to 15%) can occur in patients who have a history of hypersensitivity to penicillins, so clinicians must consider the degree of cross reactivity and reaction to penicillin before using a carbapenem in a penicillin- allergic patient.

a. Immediate or accelerated hypersensitivity reactions (anaphylaxis, laryngeal edema, hives, bronchospasm) – avoid other cross-reactive - lactams, such as carbapenems.

b. Delayed hypersensitivity reactions (rash, pruritus) – give other - lactams with caution keeping in mind the degree of cross-reactivity.

B. Gastrointestinal

1. Nausea, vomiting, and diarrhea have been reported in up to 5% of patients receiving carbapenems.

2. Antibiotic-associated pseudomembranous colitis (C. difficile).

C. Central nervous system – direct toxic effect

1. Insomnia, agitation, confusion, dizziness, hallucinations, and depression.

2. Seizures - have been reported in patients receiving imipenem (1.5%), meropenem (0.5%), ertapenem (0.5%), and doripenem (<0.5%).

a. Historically, initial imipenem dosage recommendations were 1 gram every 6 hours without specific guidelines for dose adjustment in renal insufficiency - may have led to the initial increased incidence of seizures. Today, 500 mg every 6 hours is used with dosage adjustments in renal dysfunction, and the incidence of seizures has decreased.

b. Risk factors for the development of seizures during carbapenem therapy include preexisting CNS disorders (e.g. history of seizures, brain lesions, recent head trauma), high doses (> 2 grams imipenem per day), and the presence of renal dysfunction.

D. Other adverse effects associated with carbapenems include thrombophlebitis, neutropenia, thrombocytopenia, transient LFT increases, and yeast infections.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

MONOBACTAMS

I. INTRODUCTION

Naturally occurring monobactams are produced by various bacteria found in soil, and generally have only weak antibacterial activity. Synthetic monobactams, such as aztreonam, have greater antimicrobial potency and display stability against hydrolysis by some - lactamase enzymes. Currently, aztreonam is the only monobactam antibiotic available in the United States.

II. CHEMISTRY

A. Aztreonam is a synthetic monocyclic, -lactam antibiotic (monobactam). Unlike other currently available -lactam antibiotics that are bicyclic and contain a ring fused to the -lactam ring, aztreonam contains only a -lactam ring with various side chains.

B = β-lactam ring

III. MECHANISM OF ACTION

A. Like bicyclic -lactam antibiotics, aztreonam is bactericidal because of its ability to bind to and inhibit PBPs and ultimately inhibit peptidoglycan synthesis, which is essential for the synthesis, assembly and maintenance of bacterial cell walls.

B. Aztreonam binds preferentially to PBP-3 in aerobic gram-negative bacilli, interfering with cell wall synthesis. Aztreonam has poor affinity for PBPs of gram-positive and anaerobic bacteria.

IV. MECHANISMS OF RESISTANCE

A. Hydrolysis by bacterial -lactamase enzymes - aztreonam is relatively stable against hydrolysis by some plasmid- and chromosomally-mediated -lactamases; aztreonam is hydrolyzed by some -lactamases produced by Klebsiella spp., Enterobacter spp., and Pseudomonas aeruginosa.

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

B. Alteration in outer membrane porin proteins in gram-negative bacteria leading to decreased permeability.

V. SPECTRUM OF ACTIVITY

A. Aztreonam preferentially binds to PBP-3 in gram-negative aerobic bacteria; therefore, aztreonam only has activity against gram-negative aerobes.

1. Gram-positive aerobes - inactive

2. Gram-negative aerobes - aztreonam is active against a wide range of gram- negative aerobes including:

Haemophilus influenzae Moraxella catarrhalis Citrobacter spp. Enterobacter spp. E. coli Klebsiella pneumoniae Proteus spp. Morganella morganii Providencia spp. Serratia marcescens Salmonella spp. Shigella spp. Pseudomonas aeruginosa

3. Anaerobes - inactive

VI. PHARMACOLOGY – only available IV

A. Distribution - Aztreonam is widely distributed into body tissues and fluids including skeletal muscle, adipose tissue, skin, bone, gallbladder, liver, lungs, prostatic tissue, endometrium, sputum, bronchial secretions, aqueous humor, bile, pleural fluid, peritoneal fluid, and synovial fluid. Aztreonam DOES penetrate into the CSF, especially in the presence of inflamed meninges.

B. Elimination - Aztreonam is excreted principally in the urine as unchanged drug. The half- life of aztreonam is 1.3 to 2.2 hours in patients with normal renal function. Doses need to be adjusted in patients with renal insufficiency, and aztreonam is removed during hemodialysis.

C. Dosing in normal renal function

Adults: 0.5 to 2 grams IV every 8 hours Pediatric: 30 to 50 mg/kg IV every 8 hours

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Cephalosporins, Carbapenems, and Monobactams December 1, 2009 Joseph R. Lentino,M.D.,Ph.D.

VII. CLINICAL USES

A. Aztreonam can only be used for the treatment of infections caused by gram-negative aerobes such as complicated and uncomplicated urinary tract infections, lower respiratory tract infections, meningitis, bacteremia, skin and skin structure infections, intraabdominal infections, and gynecologic infections caused by susceptible gram- negative aerobes. If anaerobes are known or suspected, metronidazole or clindamycin should be added.

B. Aztreonam is especially useful for the treatment of gram-negative infections in patients with a history of a severe penicillin allergy.

VIII. ADVERSE EFFECTS

A. Hypersensitivity - rash, pruritus, urticaria, angioedema, anaphylaxis (rare). Studies in rabbits and humans suggest that antibodies directed against penicillin show negligible cross-reactivity with aztreonam. Because of a low to negligible incidence of cross- reactivity, aztreonam can be used in a patient with a history of penicillin allergy.

B. Gastrointestinal - diarrhea, nausea, vomiting in 1 to 2% of patients

C. Other: neutropenia, thrombocytopenia, eosinophilia, transient LFT increases, phlebitis, drug fever

20 Antibiotics vs Gram-Positive Organisms Gail Reid, MD [email protected]

Vancomycin Linezolid Daptomycin

Mycozonook.com

Learning Objectives

• Understand Mechanisms of Action • Understand Mechanisms of Resistance • Learn Spectrum of Activity • Understand Pharmacokinetic Characteristics • Know Major Clinical Uses • Know Major Adverse Reactions • Know Major Drug Interactions

• Staph •Strep •Listeria • Clostridium • Bacillus • Actinomyces

Bacteriainphotos.com; eyepathologist.com Vancomycin

• Commercially-available since 1956 • Underwent extensive purification → ↓ AEs • Clinical use ↓ with introduction of antistaphylococcal penicillins • ↑ Use due to more MRSA and PRSP • Complex tricyclic glycopeptide produced by Streptomyces orientalis, MW = 1500 Da

Beerclubnj.com

Vancomycin Mechanism of Action

• Inhibits bacterial cell wall synthesis at a site different than -lactams • Inhibits synthesis and assembly of the second stage of cell wall synthesis • Binds firmly to D-alanyl-D-alanine portion of cell wall precursors to prevent cross-linking and further elongation of peptidoglycan; weakens cell wall • Time-dependent bactericidal activity; slowly kills bacteria (static against Enterococcus)

Vancomycin

cid.oxfordjournals.co Vancomycin Mechanism of Resistance

• Resistance in VRE and VRSA due to modification of D-alanyl-D-alanine binding site of peptidoglycan  Terminal D-alanine replaced by D-lactate  Loss of critical hydrogen bond  Loss of antibacterial activity  3 phenotypes - vanA, vanB, vanC • VISA – thickened cell wall

Vancomycin Spectrum of Activity

Gram-positive bacteria  Methicillin-Susceptible AND Methicillin-Resistant S. aureus and coagulase-negative staphylococci*  Streptococcus pneumoniae (including PRSP*), viridans streptococcus, Group streptococcus  Enterococcus spp.  Corynebacterium, Bacillus. Listeria, Actinomyces  Clostridium spp. (including C. difficile*), Peptococcus, Peptostreptococcus No activity vs gram-negative organisms

* = target organisms

Vancomycin Pharmacology

• Time-dependent bactericidal activity • Interpatient variability in Vd and Cl also exists for vancomycin • Absorption  Absorption from GI tract is negligible after oral administration, except in patients with colitis  Must use intravenous therapy for treatment of systemic infections Vancomycin Pharmacology

Distribution  Widely distributed into body tissues and fluids, including adipose tissue - use TBW for dosing  Variable penetration into CSF, even with inflamed meninges  Takes one hour to distribute from plasma into tissue compartment (peak drawn later)  Normal Vd = 0.5 - 0.65 L/kg  Vd increased in neonates

Vancomycin Pharmacology

Elimination  Primarily eliminated unchanged by the kidney via glomerular filtration  Elimination half-life depends on renal function  6 to 8 hours with normal renal function  Progressively increases with degree of renal dysfunction (7-14 days in pts with ESRD)  NOT removed by hemodialysis Vancomycin Serum Concentration Monitoring

• Lack of well-controlled studies relating serum concentrations to efficacy or toxicity • Variability in Vd and Cl may necessitate concentration monitoring in some patients • Peak - should be drawn 60 minutes after a the end of infusion; falsely elevated if drawn too early (during distribution phase)  Target = 30 to 40 mcg/ml • Trough - prior to next dose  Target = 5 to 15 mcg/ml

Vancomycin Dosing • Consider differences in Vd and Cl when determining dose for each patient • Several dosing nomograms are available • Adults  Normal renal function: 10 - 15 mg/kg every 12 hours (typically 1 to 1.5 grams)  Impaired renal function: 10 - 15 mg/kg/dose with interval based on renal function  Use TBW for dosing, unless > 200kg • Neonates and children  10 - 15 mg/kg/dose with interval based on age

Vancomycin Clinical Uses

• Infections due to methicillin-resistant staph including bacteremia, empyema, endo- carditis, peritonitis, pneumonia, skin and soft tissue infections, osteomyelitis, meningitis • Serious gram-positive infections in -lactam allergic patients • Infections caused by multidrug resistant bacteria (PRSP) • Endocarditis or surgical prophylaxis in select cases • Oral vancomycin for moderate to severe C. difficile colitis Vancomycin Adverse Effects

Red-Man Syndrome  Flushing, pruritus, erythematous rash on face, neck, and upper torso within 5 to 15 minutes of starting infusion  Related to RATE of intravenous infusion; doses should be infused over at least 60 minutes (no faster than 15 mg per minute)  Resolves spontaneously after discontinuation  May lengthen infusion (over 2 to 3 hours) or pre-treat with antihistamines in some cases

Vancomycin Adverse Effects

• Nephrotoxicity and Ototoxicity  Rare with vancomycin monotherapy, more common when administered with other nephro- or ototoxins  Risk factors include renal impairment, prolonged therapy, high doses, ? high serum concentrations, use of other nephro- or ototoxins • Dermatologic - rash • Hematologic - neutropenia and thrombo- cytopenia with prolonged therapy • Thrombophlebitis, interstitial nephritis

Oxazolidinones

• Linezolid (Zyvox®) is the first FDA approved agent (2000) PO and IV • Developed in response to need for antibiotics with activity against resistant gram-positives (VRE, MRSA, VISA) • Linezolid is a semisynthetic oxazolidinone, which is a structural derivative of earlier agents in this class Linezolid Mechanism of Action • Binds to the 50S ribosomal subunit near the surface interface of 30S subunit – causes inhibition of 70S initiation complex (unique binding site), which inhibits protein synthesis • Bacteriostatic (cidal vs Strep pneumoniae) Mechanism of Resistance • Alterations in ribosomal binding sites - rare • Cross-resistance with other protein synthesis inhibitors is unlikely

Linezolid

Chm.bris.ac.uk;

Linezolid Spectrum of Activity Gram-Positive Bacteria  Methicillin-Susceptible, Methicillin-Resistant AND Vancomycin-Resistant Staph aureus* and coagulase-negative staphylococci  Streptococcus pneumoniae (including PRSP*), viridans streptococcus, Group streptococcus  Enterococcus faecium AND faecalis (including VRE)*  Bacillus. Listeria, Clostridium spp. (except C. difficile), Peptostreptococcus, P. acnes Gram-Negative – inactive Atypical Bacteria (some activity)  Mycobacteria

* = target organisms Linezolid Pharmacology

• Time-dependent bactericidal activity • Post Abx Effect for Gram-Positives  3 to 4 hours for S. aureus and S. pneumoniae  0.8 hours for Enterococcus • Absorption – 100% bioavailable • Distribution – readily distributes into well- perfused tissue; CSF penetration  30% • Elimination – both renally and nonrenally, but primarily metabolized; t½ is 4.4 to 5.4 hours; no adjustment for RI; removed by HD

Linezolid Clinical Uses and Dosing

• Very expensive - $75 to $140 per day (600 mg every 12 hours IV or PO) • Use reserved for serious/complicated infections caused by resistant gram-positive bacteria:  VRE bacteremia, NOT urinary tract infections  Complicated skin and soft tissue infections due to MSSA, MRSA or Streptococcus pyogenes  Nosocomial pneumonia due to MRSA • Data is accumulating in the treatment of serious infections due to MRSA or VRE (endocarditis, meningitis, osteo); catheter-related bacteremia Linezolid Drug Interactions

• Has potential to interact with adrenergic or serotonergic agents

 Enhancement of pressor response to agents such as dopamine or epinephrine

 Serotonin syndrome with SSRIs/MAOIs – hyperpyrexia, diarrhea, cognitive dysfunction, restlessness, seizures, coma . May need two week washout period

Linezolid Adverse Effects

• GI – nausea, vomiting, diarrhea (6 to 8 %), lactic acidosis • Headache – 6.5% • Peripheral neuropathy • Thrombocytopenia or anemia: > 2-4%  Most often with treatment > 10- 14 days  Therapy should be discontinued – counts will return to normal

Lipopeptides

• Daptomycin (Cubicin) is a cyclic lipopeptide antibiotic with activity vs resistant gram-positives (VRE, MRSA, VISA) • FDA-approved September 2003 • Derived from Streptomyces roseosporus • Large molecular weight = 1620 Da Daptomycin

Mechanism of Action • Binds to bacterial membranes → rapid depolarization of membrane potential → inhibition of protein, DNA, and RNA synthesis • Concentration-dependent bactericidal activity Mechanism of Resistance • Rarely reported in VRE and MRSA due to altered cell membrane binding

Daptomycin

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Daptomycin Spectrum of Activity

Gram-Positive Bacteria  Methicillin-Susceptible, Methicillin-Resistant AND Vancomycin-Resistant Staph aureus* and coagulase-negative staphylococci  Streptococcus pneumoniae (including PRSP*), viridans streptococcus, Group streptococcus  Enterococcus faecium AND faecalis (including VRE)* Gram-Negatives – inactive

* = target organisms Daptomycin Pharmacology

• Concentration-dependent bactericidal activity •IV • Distribution – readily distributes into well- perfused tissue; protein binding = 90% • Elimination – excreted primarily by the kidneys (78%); t½ is 7.7 to 8.3 hours in normal renal function; dosage adjustments are required in the presence of RI; not removed by HD

Daptomycin Clinical Uses and Dosing

• Very expensive - $165 per day (6 mg/kg/day) • Use reserved for serious/complicated infections caused by resistant bacteria:  Complicated skin and soft tissue infections due to MSSA, MRSA, or Streptococcus pyogenes  Bacteremia due to Staphylococcus aureus  Data accumulating in treatment of serious infections due to MRSA or VRE (endocarditis, meningitis, osteo); catheter-related bacteremia • Daptomycin should NOT be used in the treatment of pneumonia

Daptomycin

• Adverse Effects  Gastrointestinal – nausea, diarrhea  Headache  Injection site reactions  Rash  Myopathy and CPK elevation - <2% • Drug Interactions  HMG CoA-reductase inhibitors – may lead to increased incidence of myopathy Questions? Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

FLUOROQUINOLONES

Date: October 23 at10:30 am

Suggested Reading Assignment: Walker RC. The fluoroquinolones. Mayo Clinic Proceedings 1999;74:1030-7.

Learning Objectives:

1. Describe the mechanism of action of the fluoroquinolones. 2. Describe the mechanisms by which bacteria develop resistance to the fluoroquinolone antibiotics. 3. List the spectrum of activity of the older and newer/respiratory fluoroquinolones. List the fluoroquinolones that have the best activity against Staphylococcus aureus, Streptococcus pneumoniae, Pseudomonas aeruginosa, atypical bacteria, and anaerobes. 4. Describe the major pharmacokinetic differences between the fluoroquinolones in terms of oral bioavailability, half-life, dosing interval, penetration into the CSF, route of excretion, necessity for dosage adjustment in renal insufficiency, and removal by hemodialysis. 5. Discuss the main clinical uses of ciprofloxacin, levofloxacin, and moxifloxacin. 6. List the major adverse effects associated with fluoroquinolone therapy. 7. Explain the major drug interactions that may occur with the fluoroquinolone antibiotics. 8. Name the fluoroquinolones that are currently available in the US, including the dosage forms that are available.

Drugs Covered in this Lecture:

Ciprofloxacin, Levofloxacin, Moxifloxacin, Gemifloxacin

1 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

FLUOROQUINOLONES

I. INTRODUCTION

The fluoroquinolone antibiotics are a novel group of synthetic antibiotics developed in response to the need for antibiotics with activity against resistant bacteria. All of the quinolones available today are structural derivatives of the original prototype agent of this class, nalidixic acid. The usefulness of nalidixic acid was hindered by the rapid development of bacterial resistance (even during therapy) and limited therapeutic utility. The introduction of the fluorinated 4-quinolones (hence the name fluoroquinolones {FQs}: ciprofloxacin, ofloxacin, levofloxacin, gatifloxacin, moxifloxacin, gemifloxacin) represents a particularly important therapeutic advance as these agents have broad antimicrobial activity, excellent oral bioavailability, extensive tissue penetration, and relatively long serum half-lives. Like other antibiotic classes, the main disadvantage of the FQs is the emergence of resistance in certain organisms.

II. CHEMISTRY

A. Currently available fluoroquinolones have two six-membered rings containing a nitrogen at position 1, a carboxylic acid moiety at position 3, a carbonyl group at position 4, a fluorine at position 6, and a piperazine moiety or other group at position 7.

Responsible for R O interaction with Enhances tissue divalent and trivalent penetration and cations binding at topoisomerases F COOH

R7 X N l Piperazine group at R7 R provides activity against Pseudomonas

III. MECHANISM OF ACTION

A. The FQs have a unique mechanism of action that includes inhibition of DNA synthesis by binding to and inhibiting bacterial topoisomerases, which are enzymes needed for maintaining cellular DNA in an appropriate state of supercoiling in both the replicating and nonreplicating regions of the bacterial chromosome.

2 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

B. The FQs target bacterial DNA gyrase (topoisomerase type II) and topoisomerase IV:

1. Inhibition of DNA gyrase prevents the relaxation of positively supercoiled DNA that is required for normal transcription and replication. The FQs form a stable complex with DNA and DNA gyrase, which blocks the replicating fork leading to a sudden and lethal cessation of DNA replication. For many gram-negative bacteria, DNA gyrase is the primary target of the FQs.

2. Inhibition of topoisomerase IV interferes with separation of replicated chromosomal DNA into the respective daughter cells during cell division that are the product of DNA replication, causing a cessation in DNA replication. For many gram-positive bacteria (S. aureus), topoisomerase IV is the primary target of the FQs.

C. The FQs display concentration-dependent bactericidal activity.

IV. MECHANISMS OF RESISTANCE

A. Altered binding sites – chromosomal mutations in the genes that code for the subunits of topoisomerase IV or DNA gyrase lead to decreased binding affinity of the FQs to these target sites.

1. S. aureus and P. aeruginosa require only a single mutation in the genes encoding for the topoisomerases to become resistant.

2. E. coli and S. pneumoniae often require more than one mutation to become resistant to the newer FQs.

B. Expression of active efflux – efflux pump is turned on that enhances the transfer of FQs out of the cell; reported in P. aeruginosa and S. pneumoniae.

C. Altered cell wall permeability – chromosomal mutations cause decreased expression of porin proteins that are responsible for FQ transit inside the cell leading to decreased FQ accumulation within the cell (rare).

D. Cross-resistance is usually observed between the FQs.

V. SPECTRUM OF ACTIVITY – older (ciprofloxacin) versus newer/respiratory FQs (levofloxacin, moxifloxacin, gemifloxacin)

A. Gram-positive aerobes – ciprofloxacin has poor activity against gram-positive bacteria; the newer FQs (levofloxacin, trovafloxacin, gatifloxacin, moxifloxacin, gemifloxacin) have enhanced activity against gram-positive bacteria

. Methicillin-susceptible S. aureus (not MRSA) . Streptococcus pneumoniae (including PRSP – except ciprofloxacin)

3 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

. Group and viridans streptococci, Enterococcus spp. – limited activity

B. Gram-negative aerobes – some FQs have excellent activity against Enterobacteriaceae (ciprofloxacin=levofloxacin>gatifloxacin>gemifloxacin, moxifloxacin), H. influenzae, M. catarrhalis, and Neisseria species

Haemophilus influenzae Moraxella catarrhalis Citrobacter spp. Enterobacter spp. Escherichia coli Klebsiella pneumoniae Proteus spp. Morganella morganii Providencia spp. Serratia marcescens Salmonella spp. Shigella spp. Campylobacter spp Neisseria spp. Pseudomonas aeruginosa (cipro ≥ levo > gati; NOT moxi)

C. Anaerobes – trovafloxacin had adequate activity against anaerobes including Bacteroides fragilis; moxifloxacin has some activity

D. Atypical Bacteria – most FQs are extremely active against Legionella, Chlamydophila, Mycoplasma, and Ureaplasma

E. Other Organisms – have activity against Mycobacterium tuberculosis (levo, moxi) and Bacillus anthracis (cipro, levo)

VI. PHARMACOLOGY (see PK chart page 5)

A. FQs exhibit concentration-dependent bactericidal activity (AUC/MIC {30 to 50 for S. pneumoniae; 100 to 125 for gram-negatives} or Peak/MIC correlate with clinical efficacy) and display a PAE against both gram-positive (2 hours) and gram-negative aerobic bacteria (2 to 4 hours).

B. Absorption

1. FQs are well absorbed after oral administration (except for norfloxacin, F = 50%); oral bioavailability is 70 to75% for ciprofloxacin and > 90% for levofloxacin and moxifloxacin – allows for early conversion to oral therapy.

2. Tmax is achieved within 1 to 2 hours; coingestion with food delays peak serum concentrations.

C. Distribution

1. Most of the FQs display extensive tissue penetration obtaining therapeutic concentrations in the prostate, liver, lung, bronchial mucosa, sputum, bile, saliva, skin and soft tissue, bone and into alveolar macrophages.

4 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

2. Most FQs achieve high urinary concentrations (except for moxifloxacin, trovafloxacin, and gemifloxacin) making them useful for the treatment of urinary tract infections and prostatitis.

3. FQs achieve minimal penetration into the CSF.

D. Elimination

1. FQs are eliminated by various pathways

a. Renal elimination – levofloxacin, ofloxacin, and gatifloxacin are eliminated primarily by the kidney (glomerular filtration and tubular secretion); dosage adjustments of these agents are necessary in the presence of renal insufficiency

b. Hepatic metabolism and elimination – trovafloxacin and moxifloxacin are primarily metabolized

c. Ciprofloxacin and gemifloxacin undergo both renal and hepatic elimination; doses of both agents should be adjusted in the presence of renal insufficiency

d. NONE of the FQs are removed during hemodialysis

PHARMACOKINETIC TABLE Agent Dose F Cmax AUC Half-life Protein % Renal (%) (g/ml) (mg*hr/ml) (hours) Binding Excretion (%) Norfloxacin 400 mg PO 50 1.5 13.6 3.3 15 40 Ciprofloxacin 500 mg PO 70 2.4 29 4 25 60 400 mg IV 4.6 5 - 6 Ofloxacin 400 mg PO 95 4.6 35 4 - 5 25 90 400 mg IV 5.5 6 Levofloxacin 500 mg PO 99 5.7 45 – 50 6 - 8 25 90 500 mg IV 6.4 6 - 8 750 mg PO 8.6 91 750 mg IV 12.1 108 Gatifloxacin 400 mg PO 96 3.4 32 6.5 - 8.4 18 80 No longer available 400 mg IV 4.6 Moxifloxacin 400 mg PO 90 4.3 39 - 48 9.2 50 20 400 mg IV 4.2 Gemifloxacin 320mg PO 71 1.6 9.9 7 60 - 70 36

5 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

E. DOSING Parenteral (IV) Oral

CIPROFLOXACIN (Cipro) 200 to 400 mg q8-12h 250 to 750 mg BID OFLOXACIN (Floxin) 400 mg q12h 400 mg q12h LEVOFLOXACIN (Levaquin) 250 to 750 mg QD 250 to 750 mg QD TROVAFLOXACIN (Trovan) 200 mg QD 200 mg QD MOXIFLOXACIN (Avelox) 400 mg QD 400 mg QD NORFLOXACIN (Noroxin) 400 mg q12h GEMIFLOXACIN (Factive) 320 mg QD

VII. CLINICAL USES

A. Community-acquired pneumonia – levofloxacin, moxifloxacin, and gemifloxacin

B. Acute exacerbations of chronic bronchitis and sinusitis – ciprofloxacin, levofloxacin, moxifloxacin, and gemifloxacin

C. Bacterial exacerbations in cystic fibrosis (P. aeruginosa) - ciprofloxacin

D. Nosocomial pneumonia – ciprofloxacin and levofloxacin

E. Urinary tract infections (cystitis, pyelonephritis) – ciprofloxacin, levofloxacin; norfloxacin (cystitis only)

F. Chronic Bacterial Prostatitis – ciprofloxacin and levofloxacin

G. Osteomyelitis - ciprofloxacin

H. Other – intraabdominal infections (ciprofloxacin or levofloxacin with metronidazole, moxifloxacin alone); traveler’s diarrhea (ciprofloxacin, norfloxacin); tuberculosis (ciprofloxacin, levofloxacin, moxifloxacin); STDs; febrile neutropenia prophylaxis and treatment (ciprofloxacin); eye infections

VIII. ADVERSE EFFECTS – many FQs have been removed from the market due to adverse effects; FQs still available are well tolerated.

A. Gastrointestinal (5%) – nausea, vomiting, diarrhea, dyspepsia, Clostridium difficile colitis

B. CNS – headache, confusion, agitation, insomnia, dizziness (trovafloxacin 11%); rarely hallucinations and seizures

6 Pharmacology/Therapeutics Fluoroquinolones October 23, 2012 David W. Hecht, MD, MS, MBA.

C. Hepatotoxicity – transaminase elevation; trovafloxacin was associated with 140 cases of severe liver injury and 14 cases of fulminant liver failure, use was restricted to the treatment of severe infections in hospitalized patients or patients in LTCF where therapy could be closely monitored – now withdrawn from market; moxifloxacin has also been associated with a few cases of liver failure

D. Phototoxicity – highest incidence with earlier FQs including lomefloxacin, sparfloxacin and enoxacin (agents with an additional fluorine or chlorine at position 8); patients are required to avoid exposure to sunlight or UV light

E. Cardiac – FQs may cause slight prolongation in QTc interval, excessive prolongation can lead to Torsades; most significant with sparfloxacin and grepafloxacin (both removed from the market); several case reports of Torsades with ciprofloxacin, levofloxacin, gatifloxacin and moxifloxacin; FQs should be used with caution in patients with hypokalemia, concomitant use of class III antiarrhythmics (amiodarone, sotalol), preexisting QTc prolongation

F. Articular Damage – arthropathy (articular cartilage damage, arthralgias and joint swelling) observed in young experimental animals led to the contraindication in pediatric patients and the warning to avoid their use in pregnant or breastfeeding patients; FQs have been used in a substantial number of pediatric patients without apparent arthropathy (risk versus benefit)

G. Tendonitis and Tendon Rupture – especially in patients over 60 years of age receiving corticosteroids, or who have undergone a renal, heart or lung transplant; patient should avoid exercise if tendon pain develops while on therapy

H. Other: allergic reactions (rare), dysglycemias (gatifloxacin removed from market)

IX. DRUG INTERACTIONS

A. Divalent and trivalent cations (Zinc, Iron, Ca, Al, Mg– including antacids, ddI, Sucralfate, enteral feeds) may impair the absorption of ANY ORAL fluoroquinolones through chelation leading to clinical failure; doses should be administered at least 2 to 4 hours apart (tube feedings must be stopped for several hours surrounding FQ administration); give FQ first

B. Warfarin – idiosyncratic interaction leading to increased prothrombin time and potential bleeding; has been reported with most FQs

C. Theophylline – inhibition of theophylline metabolism leading to increased serum theophylline concentrations and potential toxicity; may occur with ciprofloxacin, but does not occur with levofloxacin, gatifloxacin or moxifloxacin

D. Cyclosporine – ciprofloxacin may inhibit cyclosporine metabolism leading to increased cyclosporine levels and potential toxicity

7 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

METRONIDAZOLE (Flagyl) – IV, PO, topical

Chapter 53: Antiprotozoal Drugs. In: Katzung, BG, ed. Basic and Clinical Pharmacology, 11th edition, McGraw-Hill, New York, NY, 2007.

Kasten MJ. Clindamycin, metronidazole, and chloramphenicol. Mayo Clinic Proceedings 1999;74:825-33.

Learning Objectives:

1. Describe the mechanism of action and mechanisms of resistance of metronidazole. 2. List the spectrum of activity of metronidazole, with special emphasis on their activity against anaerobes and Clostridium difficile. 3. Describe the pharmacokinetic characteristics of metronidazole with respect to oral bioavailability, distribution into the central nervous system, route of elimination, removal by hemodialysis, and dosage adjustment in end-organ dysfunction. 4. List the major clinical uses of metronidazole. 5. List the major adverse effects associated with metronidazole therapy. Describe patient counseling with regard to alcohol consumption during metronidazole therapy. 6. List the major drug interactions associated with metronidazole therapy.

Drugs Covered in this Lecture:

Metronidazole

I. INTRODUCTION

Metronidazole is a synthetic nitroimidazole antibiotic originally recognized to display potent activity against certain protozoa including Trichomonas, Giardia, and Entamoeba. Studies conducted over a decade later revealed that metronidazole had extremely useful clinical activity against a wide variety of gram-positive and gram-negative anaerobic pathogens. Metronidazole is now considered one of the most useful agents in the treatment of anaerobic and polymicrobial infections in the US.

II. CHEMISTRY

A. Metronidazole was derived from azomycin by chemical synthesis and biological testing. Its chemical name is 1-(-hydroxyethyl)-2-methyl-5-nitroimidazole.

1 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

With permission from: Katzung’s Basic and Clinical Pharmacology, 10th edition, 2007, page 857

III. MECHANISM OF ACTION

A. Metronidazole is a prodrug that is activated by a reductive process. Its selective toxicity towards anaerobic and microaerophilic bacteria is due to the presence of electron transport components such as ferredoxins within these bacteria. Ferredoxins are small Fe-S proteins that donate electrons to metronidazole to form a highly reactive nitro radical anion.

B. These short-lived activated metabolites damage bacterial DNA (inhibit nucleic acid synthesis), and subsequently cause cell death – metronidazole is rapidly bactericidal in a concentration-dependent manner.

C. Metronidazole is catalytically recycled when loss of the electron from the active metabolite regenerates the parent compound.

D. Increased levels of oxygen inhibit metronidazole-induced cytotoxicity since oxygen competes with metronidazole for generated electrons. IV. MECHANISM OF RESISTANCE

A. Clinical resistance to metronidazole is well documented for Trichomonas, Giardia, and a variety of anaerobic bacteria, but is relatively uncommon.

1. Altered growth requirements – organism grows in higher local oxygen concentrations causing decreased activation of metronidazole and futile recycling of the active drug

2. Altered levels of ferredoxin – reduced transcription of the ferredoxin gene

V. SPECTRUM OF ACTIVITY

2 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

A. Metronidazole is extremely active against a wide variety of anaerobic protozoal parasites and anaerobic bacteria. It is the antianaerobic agent most reliably active against Bacteroides fragilis.

B. Gram-negative anaerobes – highly active against cocci and bacilli

Bacteroides fragilis Bacteroides distasonis, ovatus, thetaiotamicron, bivius (B. fragilis group DOT organisms) Fusobacterium Prevotella spp. Helicobacter pylori (an obligate anaerobe)

C. Gram-positive anaerobes – active against cocci (variably) and sporulating bacilli

Clostridium spp. (including Clostridium difficile)

C. Other organisms

Trichomonas vaginalis Entamoeba histolytica Giardia lamblia Gardnerella vaginalis

E. Metronidazole is inactive against all common aerobic and facultatively anaerobic bacteria.

VI. PHARMACOLOGY

A. Absorption

1. Metronidazole is rapidly and almost completely absorbed after oral administration, achieving peak concentrations within 0.25 to 3 hours after administration.

2. Food does not affect the absorption of metronidazole, but may delay the Tmax.

3. Serum concentrations are similar after equivalent intravenous and oral doses. Rectal absorption is adequate but delayed, and vaginal absorption is minimal.

3 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

B. Distribution

1. Metronidazole is well distributed into body tissues and fluids, including vaginal secretions, seminal fluids, saliva, and breast milk. Repeated dosing results in some accumulation of the drug.

1. Metronidazole DOES penetrate into the CSF and brain tissue achieving 50 to 100% of simultaneous serum concentrations in the CSF depending on the degree of meningeal inflammation.

C. Metabolism/Elimination

1. Metronidazole is metabolized by the liver to several active metabolites. Metabolism accounts for over 50% of the systemic clearance of metronidazole.

2. Metronidazole and its metabolites are primarily excreted in the urine; only 10% is recovered as unchanged drug in the urine; 6-15% of a dose is excreted in the feces.

2. The elimination half-life in normal renal and hepatic function is 6 to 8 hours for the parent drug, and 12 to 15 hours for some metabolites. The half-life is prolonged in the presence of renal or hepatic dysfunction, so that dosage adjustments are required.

3. Metronidazole is removed during hemodialysis.

VII. CLINICAL USES, DOSAGES, AND ADMINISTRATION – available orally as 250mg and 500 mg tablets; 500 mg for parenteral use; intravaginal gel

A. Infections due to anaerobes (including serious infections) such as skin and soft tissue infections, bone and joint infections, intraabdominal and pelvic infections or abscesses, brain abscesses, diabetic foot infections, etc. Many serious anaerobic infections are polymicrobial, and additional agents are necessary for coverage of other causative organisms (aerobes).

1. Oral: 250 mg to 500 mg every 6 to 8 hours

2. Parenteral: typical adult dose is 500 mg every 6 hours; maximum dose is 4 grams daily

4 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

B. Pseudomembranous colitis due to Clostridium difficile – DRUG OF CHOICE

1. Oral metronidazole is the drug of choice for mild to moderate C. difficile colitis because it is less expensive than oral vancomycin with similar treatment outcomes and less impact on microbial ecology in the intestinal tract.

2. Oral or parenteral therapy may be used: 250 mg to 500 mg every 6 to 12 hours

C. Bacterial vaginosis due to Gardnerella vaginalis – oral (500 mg twice daily for 7 days) or intravaginal therapy (5 g twice daily for 5 days)

D. Trichomonas vaginalis – 2 grams orally as a single dose; 500 mg PO twice daily for 5 days; 250 mg PO every 8 hours for 7 days

E. Amebiasis (intestinal or extraintestinal) – 750 mg PO or IV every 8 hours for 10 days

F. Other: H. pylori (250 mg to 500 mg PO every 8 hours with other meds); Crohn’s diseases (intestinal bacterial overgrowth); acne rosacea; gingivitis

VIII. ADVERSE EFFECTS

A. Gastrointestinal – nausea, diarrhea, anorexia, metallic taste, stomatitis, pancreatitis

B. Central nervous system – most serious; rare unless large doses are utilized or therapy is prolonged

1. Seizures, encephalopathy, cerebellar dysfunction, peripheral neuropathy

2. Use with caution in patient with CNS disorders

3. If neurologic symptoms develop, the drug should be discontinued immediately

C. Other: reversible neutropenia, dark brown urine, local vaginal reactions

D. Mutagenicity and Carcinogenicity

1. Carcinogenic in rodents, especially female rats; concern about the promotion of cancer in humans (long term effects of high-dose prolonged therapy have not been studied)

2. Metronidazole may be teratogenic – should be avoided during the first trimester and during breastfeeding

5 Pharmacology & Therapeutics Metronidazole October 23, 2012 David W. Hecht, MD.

IX. DRUG INTERACTIONS

Drug Interaction

Warfarin Increased anticoagulant effect Alcohol Disulfiram reaction Phenytoin Increased phenytoin concentrations Lithium Increased lithium concentrations Phenobarbital Decreased metronidazole concentrations Rifampin Decreased metronidazole concentrations

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Miscellaneous Antibiotics: Tetracyclines, Sulfonamides, Chloramphenicol, UTI agents

Gail Reid, M.D. Infectious Diseases October 25, 2012

Lecture Objectives

Identify the key characteristics of the tetra- cyclines, glycylcyclines, sulfonamides, chloramphenicol and urinary tract agents with respect to:  Mechanism of Action  Mechanisms of Resistance  Spectrum of Activity  Pharmacology  Clinical Uses  Major Adverse Effects  Drug Interactions

Tetracyclines and Glycylcyclines

• Tetracyclines were originally discovered in the 1950s through systematic screening of soil samples  Streptomyces aureofaciens  Chlortetracycline • First Generation  Tetracycline • Second Generation  Doxycycline, Minocycline

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Micsgmjournals.org

Tetracyclines and Glycylcyclines

• Glycylcyclines  Minocycline derivatives  Structural modifications to improve spectrum of activity and overcome resistance mecanisms • Tigecycline (Tygacil®)

Tigecycline Structure

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Tetracyclines/Glycylcyclines Mechanism of Action  Reversibly binds to the 30S ribosomal subunit . Inhibit the binding of aminoacyl transfer-RNA to the acceptor (A) site on the mRNA-ribosomal complex, which prevents addition of amino acid residues on elongating peptide chain  Bacteriostatic . Bactericidal when present at high concentrations against very susceptible organisms

Tetracycline

faculty.ccbcmd.edu

Tetracyclines/Glycylcyclines • Mechanisms of Resistance Acquisition of genes on mobile elements • Efflux Pumps  accumulation of tetracycline within bacteria • Ribosomal protection proteins • Cytoplasmic proteins that protects ribosomes from 1st and 2nd generation tetracyclines • Enzymatic inactivation • Cross-resistance observed between tetracyclines, except for minocycline • Tigecycline resistant to these mechanisms

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Tetracyclines In Vitro Spectrum of Activity

Gram-Positive Aerobes

• Staphylococcus aureus (primarily MSSA) • Streptococcus pneumoniae – PSSP (doxycycline – 83% susceptible) • Bacillus spp, Listeria spp, Nocardia spp

Tetracyclines In Vitro Spectrum of Activity

Gram-Negative Aerobes • N. gonorrhea and meningitidis • Haemophilus influenzae (90% susceptible) • Haemophilus ducreyi (chancroid) • Campylobacter jejuni • Helicobacter pylori • Vibrio cholerae, Vibrio vulnificus

• Pseudomonas pseudomallei

Tetracyclines In Vitro Spectrum of Activity

Anaerobes Actinomyces Propionibacterium Miscellaneous Bacteria Bartonella, Bordetella, Brucella, Pasteurella Legionella, Chlamydophila, Chlamydia, Mycoplasma, Ureaplasma Borrelia, Treponema, Leptospira Rickettsia, Coxiella Mycobacterium fortuitum

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Tigecycline Spectrum of Activity Gram-Negative Aerobes • Acinetobacter baumannii • Aeromonas hydrophila • Citrobacter spp. • Escherichia coli • Klebsiella spp. • Serratia marcescens • Stenotrophomonas maltophilia • NOT Proteus spp or Pseudomonas aeruginosa Anaerobes • Clostridium perfringens, Bacteroides spp

Tigecycline Spectrum of Activity Gram-Positive Aerobes • Staphylococcus aureus • MSSA, MRSA • Enterococcus spp • VRE, VSE

• NOT for bacteremias or UTIs

Tetracyclines/Glycylcyclines Pharmacology

Absorption  Only doxycycline is available PO and IV; tigecycline is only available IV  Tetracycline and demeclocycline F = 60 to 80%  Doxycycline and minocycline F = 90 to 100%  Absorbed best on an empty stomach  Absorption impaired by di- and trivalent cations Distribution  Widely distributed with good penetration into synovial fluid, prostate, seminal fluid  Minimal CSF penetration

5 10/26/2012

Tetracyclines/Glycylcyclines Pharmacology Elimination  Demeclocycline/tetracycline - excreted unchanged in the urine . dosage adjustment required in renal insufficiency . Tetracycline half-life = 6 to 12 hours; demeclocycline half- life = 16 hours  Doxycycline, minocycline (metab) and tigecycline (biliary) - excreted mainly by non-renal routes . Half-lives = 16-18 hours (doxy, mino); 27-42 hours (tige) – yet they are all dosed every 12 hours! . Do NOT require dosage adjustment in the presence of renal insufficiency. Adjust tigecycline with liver disease  Tetracyclines/tigecycline are minimally removed during hemodialysis

The Clinical Uses of Tetracyclines/Glycylcyclines

• Respiratory infections  Community-acquired pneumonia (doxy)  Acute exacerbation of chronic bronchitis  Pertussis • STDs –Chlamydia, Syphilis, gonorrhea • Treatment or prophylaxis of malaria • The Others:  Rocky Mountain Spotted Fever, Q Fever, Lyme  Brucellosis, Bartonellosis, plague, Tularemia, chancroid, anthrax, H. pylori

cdc.gov; en.wikipedia.org;

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The Clinical Uses of Tetracyclines/Glycylcyclines

• Polymicrobial infections (Tigecycline)  Complicated skin and soft tissue infections  Intraabdominal infections

• Acne

• SIADH (demeclocycline)

Tetracycline/Tigecycline Adverse Effects • Gastrointestinal  Nausea, vomiting – high incidence with tigecycline (29%)  Diarrhea, pseudomembranous colitis

• Hypersensitivity  Rash, pruritus, urticaria, angioedema, anaphylaxis

• Photosensitivity  Exaggerated sunburn

Tetracycline

Tabletsmanual.com;

7 10/26/2012

photosensitivity

Reference.medscape.com; forhealty.com

Tetracycline/Tigecycline Adverse Effects • Renal  Fanconi-like syndrome with outdated tetracycline  Reversible dose-related diabetes insipidus (demeclocycline)

• Other  Hepatic enzyme elevation

• Pregnancy Category D  Discoloration of permanent teeth and decreased bone growth in children

Tetracycline

Emdental.com;

8 10/26/2012

Sulfonamides and Trimethoprim

Sulfonamides

• The first effective antibiotics used to prevent and treat infections

• Led to a dramatic reduction in morbidity/ mortality associated with treatable infections

• Inhibits dihydropteroate synthetase – • Inhibits incorporation of p-aminobenzoic acid (PABA) into tetrahydropteroic acid

• Bacteriostatic

Sulfonamides

• Short- or Medium-Acting  Sulfisoxazole  Sulfamethoxazole  Sulfadiazine  Sulfamethizole • Long-Acting  Sulfadoxine . Combined with pyrimethamine (Fansidar)

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Trimethoprim

• 2,4-diamino-pyrimidine developed in the 1950s • Bacteriostatic • Inhibits dihydrofolate reductase  Interferes with conversion of dihydrofolate to tetrahydrofolate

Trimethoprim-Sulfamethoxazole (TMP-SMX, Bactrim)

In the 1970s, TMP was combined with sulfonamides

Bactericidal in combination Trimethoprim with synergistic activity (TMP) + Broader spectrum of activity

Decreased emergence of resistance Sulfamethoxazole (SMX)

PABA

Dihydropteroate Synthetase Sulfamethoxazole Dihydrofolic Acid

Dihydrofolate Reductase Trimethoprim

Tetrahydrofolic Acid

Purines

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TMP-SMX Mechanisms of resistance • Sulfonamides  Resistance widespread . Streptococci, Staphylococci, Enterobacteriacae, Neisseria sp., Pseudomonas sp., Shigella, Salmonella  PABA overproduction  Structural change of Dihydropteroate synthetase  Plasmid mediated production of drug resistant DHPS or decreased bacterial cell wall permeability to sulfonamides

TMP-SMX Mechanisms of resistance • Trimethoprim  Chromosomal or plasmid mediated  Plasmid-mediated production of dihydrofolate reductase resistant to trimethoprim  Changes in cell permeability

TMP-SMX Spectrum of Activity

Gram-Positive Gram-Negative Staph aureus (incl some Acinetobacter MRSA, CA-MRSA) Enterobacter S. pyogenes E. coli Nocardia K. pneumoniae Listeria monocytogenes Proteus Anaerobes Salmonella, Shigella No Activity Haemophilus spp. Other N. gonorrhoeae Stenotrophomonas maltophilia Pneumocystis carinii

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TMP-SMX Pharmacology

• Absorption – available IV and PO  Rapidly and completely absorbed (F > 90%)  Peaks are higher and more predictable with IV administration

• Distribution  Good distribution – lungs, urine, prostate, etc  Penetrates the CSF – TMP (30-50%), SMX (20%)  SMX is 70% protein bound

TMP-SMX Pharmacology

Elimination  Both are eliminated by the liver and kidney  TMP – 60% excreted unchanged in the urine over 24 hours  SMX – 25 to 50% excreted unchanged in the urine over 24 hours  Half-life . TMP = 11 hours . SMX = 9 hours  Dose adjustment required in patients with a CrCl < 30 ml/min

TMP-SMX Clinical Uses

• Acute, chronic, or recurrent infections of the urinary tract

• Acute or chronic bacterial prostatitis

• Skin infections due to CA-MRSA

• Bacterial Sinusitis

• Nocardia

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TMP-SMX Clinical Uses

• Pneumocystis carinii pneumonia

• Stenotrophomonas

• Toxoplasmosis

• Listeria monocytogenes

• Nocardia

TMP-SMX Adverse Effects • Gastrointestinal  Nausea, vomiting, diarrhea, glossitis  Jaundice  Hepatic necrosis

• Hematologic  Leukopenia, thrombocytopenia, eosinophilia  Acute hemolytic anemia, aplastic anemia, agranulocytosis  Megaloblastic anemia (impaired folate usage with prolonged administration)

TMP-SMX Adverse Effects • Hypersensitivity  Rash, urticaria, epidermal necrolysis, Stevens- Johnson, drug fever • CNS  Headache, aseptic meningitis, seizures • Renal toxicity  Tubular necrosis  Interstitial nephritis • Drug-induced lupus • Serum sickness-like syndrome • Other - crystalluria

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TMP-SMX Drug Interaction

Drug Interaction Phenytoin  phenytoin levels Warfarin  Anticoagulant effect Methotrexate decrease renal clearance

TMP-SMX Dosing • Oral tablets  Single Strength (SS) = 80mg TMP and 400mg SMX  Double Strength (DS) = 160mg TMP and 800mg SMX • Oral Suspension  40mg TMP and 200mg SMX per 5 ml • Intravenous Solution  16mg TMP and 80mg SMX per ml

TMP-SMX Dosing

Indication Adult Dose

Urinary tract infections One DS tablet twice daily

Prostatitis One DS tablet twice daily

GI Infections One DS tablet twice daily

CA-MRSA Skin Infections Two DS tablets twice daily

Pneumocystis carinii Treatment: 15 to 20 mg/kg TMP daily pneumonia divided every 8 hours (PO or IV) Prophylaxis: one DS tablet daily

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Chloramphenicol

Chloramphenicol Background

• Isolated from mulched field and compost • Streptomyces venezuelae • Introduced into use in U.S. in 1949 • Due to significant adverse events, this agent is not used in the U.S. • Use is common in the developing world

Chlorampenicol Mechanism of action

• Binds to 50s subunit of 70s ribosome • Prevents peptide bond formation • Static activity except for:  Haemophilus influenza  Streptococcus pneumoniae  Neisseria meningitidis

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Accessmedicine.ca;

Chloramphenicol Resistance mechanism(s) • Reduced permeability or uptake • Ribosomal mutation • Acetyltransferase inactivation  Responsible for widespread outbreaks of typhoid fever and Shigella dysentery in Central and South America, Vietnam, India

Chloramphenicol Pharmacology

• Absorption  Well absorbed by the GI tract  IV administration – peak level approximately 70% of peak following oral administration

• Distribution  Lipid soluble  Not highly protein bound (25-50%)  CSF levels 30-50% of serum levels

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Chloramphenicol Pharmacology

• Elimination  Metabolized by the liver  Enterohepatic circulation  Excreted by the kidneys • Decrease dose in liver failure • Does adjustment not required in renal failure

Chloramphenicol Antimcrobial spectrum

•Bacteria  Gram Positives . Unreliable against Staph aureus and not active against enterococci  Gram Negatives . Not active against P. aeruginosa  Anaerobes (Gram negative and Gram positive)

Chloramphenicol Antimicrobial spectrum

• Rickettsiae sp. • Spirochetes • Chlamydia • Mycoplasma

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Chloramphenicol Clinical uses • None in U.S.

• Third and Developing World  Pneumonia  Bacterial meningitis  Typhoid fever

• Rocky mountain spotted fever

Chloramphenicol Adverse Effects

• Hematologic  Reversible bone marrow suppression  Aplastic anemia (1 in 24,500 – 40,800) • Gray baby syndrome (neonates)  Abdominal distention  Vomiting  Flaccidity  Cyanosis  Circulatory collapse/Death

Pathwiki.pbworks.com; drugline.org;

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Chloramphenicol Adverse Effects

• Optic neuritis • Hypersensitivity reaction • Anaphylaxis • GI intolerance (vomiting, diarrhea) • Stomatitis • porphyria

Urinary Tract Agents

• Nitrofurantoin • Methenamine

UTI Agents Mechanism of Action

• Nitrofurantoin • Methenamine  Poorly understood  Converted in acid pH  Binds to ribosomal to ammonia and proteins formaldehyde  Inhibits translation  Formaldehyde – non- specific denaturant of  Inhibits bacterial respiration and proteins and nucleic pyruvate metabolism acids

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UTI Agents Mechanism of Resistance

• Nitrofurantoin • Methenamine  Poorly understood  Alkaline urine  Development of  No bacterial resistance resistance while on to formaldehyde treatment rare described  E. coli – Chromosomal or plasmid-mediated production of nitrofuran reductase

UTI Agents Pharmacology: absorption

• Nitrofurantoin • Methenamine  40-50% absorption  Rapid absorption after following oral oral administration administration  May be partially  Occurs in small degraded by gastric intestine acid  Enhanced with food

UTI Agents Pharmacology: distribution

• Nitrofurantoin • Methenamine  Large urine  Rapid absorption concentrations following oral dose  Low/undetectable  Broad distribution serum in tissue concentration  Therapeutic concentrations not attained in prostate

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UTI Agents Pharmacology: excretion

• Nitrofurantoin • Methenamine  Eliminated in the  Renal excretion urine  Half-life 3-4 hours . Glomerular filtration with normal renal . Tubular secretion function . Tubular reabsorption  Biliary excretion: minor  Serum half life <30 minutes

UTI Agents Clinical uses

• Nitrofurantoin • Methenamine  Acute,  Suppression or uncomplicated prophylaxis against UTIs recurrent UTIs

 Do not use for:  Do not use for: . Pyelonephritis . Established . Complicated UTi infections . Prophylaxis against catheter-associated UTI

UTI Agents - Nitrofurantoin Spectrum of activity

• Active against • Not active against  E. coli  Pseudomonas  Citrobacter, sp. aeruginosa  Group B  Proteus Streptococcus  Providencia  Staphylococcus  Morganella saprophyticus  Serratia  Enterococcus  Acinetobacter (including some strains of VRE)

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UTI Agents - Methenamine Spectrum of activity

• Methenamine has no antimicrobial activity

• Formaldehyde resistance not described and has broad antimicrobial activity

• May not be effective against urease producing organisms (Proteus)

UTI Agents - Nitrofurantoin Adverse reactions

• GI intolerance • Rashes • Acute pulmonary symptoms – reversible hypersensitivity phenomenon  Weeks to months after drug exposure  Rapid onset of fever, cough, dyspnea, myalgia  Peripheral blood eosinophilia and lower lobe pulmonary infiltrates

UTI Agents - Nitrofurantoin Adverse reactions

• Subacute and chronic pulmonary reaction  Gradual onset of progressive, non-productive cough and dyspnea  Interstitial infiltrate on CXR  Reversible but may lead to pulmonary fibrosis  May have + antinuclear antibodies  Bronchiolitis obliterans and organizing pneumonia reported

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UTI Agents - Methenamine Adverse reactions

• Generally well-tolerated • GI (nausea, vomiting) •Rash • Pruritis • Bladder irritation • Hemorrhagic cystitis (higher doses)

UTI Agents - Methenamine Adverse reactions

• Peripheral sensory neuropathy • Hepatitis • Hemolytic anemia • Leukopenia • Aplastic anemia • Megaloblastic anemia (folic acid responsive) • Eosinophilia

Urinary Tract Agents Dosing • Nitrofurantoin • Methenamine  Uncomplicated  >12 years old: 1g cystitis: 50-100 mg twice daily to 4 orally q6 hours for times daily max 7 days  6-12 y/o: 500mg to  Prophylaxis: 50- 1g twice daily 100 mg by mouth daily

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Questions??

24 10/24/2012

Protein –synthesis inhibitors

Macrolides Ketolides Streptogramins Lincosamides

Macrolide Lecture Objectives

Identify the differences between the macrolides and ketolides with respect to:  Mechanism of Action  Mechanisms of Resistance  Spectrum of Activity  Pharmacology  Clinical Uses  Major Adverse Effects  Drug Interactions

Major mechanism of resistance to antimicrobials

• Enzymatic inactivation • Target site absent: intrinsic resistance • Target site modification • Excessive binding sites • Altered cell wall permeability • Drug efflux

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Macrolides • Macrolides in clinical use today include erythromycin, clarithromycin, and azithromycin • Erythromycin is a naturally-occurring macrolide derived from Streptomyces erythreus that has a relatively narrow spectrum; and is acid labile, poorly tolerated after PO administration, and has a short elimination half-life • Structural derivatives include clarithromycin and azithromycin:  Broader spectrum of activity  Improved PK properties – better bioavailability, better tissue penetration, prolonged half-lives  Improved tolerability  Fidaxomicin: non absorbed macrolide for C. difficile colitis

Macrolide Structure

Fidoxamicin

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Macrolides Mechanism of Action  Inhibit protein synthesis by reversibly binding to the 50S ribosomal subunit . Induce dissociation of peptidyl RNA from the ribosome during the elongation phase  Macrolides typically display bacteriostatic activity, but may be bactericidal when present at high concentrations against very susceptible organisms  Erythro and clarithro display time-dependent activity; azithro is concentration-dependent

Macrolides Mechanisms of Resistance  Active efflux (accounts for 70-80% in US) – mef gene encodes for an efflux pump that pumps the macrolide out of the cell away from the ribosome; confers low level resistance to macrolides  Altered target sites (primary resistance mechanism in Europe) – encoded by the erm gene which alters the macrolide binding site on the ribosome; confers high level resistance to all macrolides, clindamycin, and Synercid®  Cross-resistance occurs between all macrolides

Macrolide Spectrum of Activity

Gram-Positive Aerobes – erythromycin and clarithromycin display the best activity (Clarithro>Erythro>Azithro) . Methicillin-susceptible Staphylococcus aureus (MSSA)* . Streptococcus pneumoniae (only PSSP) – resistance is developing . Group and viridans streptococci . Bacillus spp., Corynebacterium spp.

* = target organism

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Macrolide Spectrum of Activity

Gram-Negative Aerobes – newer macrolides with enhanced activity

(Azithro>Clarithro>Erythro)

• H. influenzae (not erythro), M. catarrhalis, Neisseria spp. • Do NOT have activity against any Enterobacteriaceae

Macrolide Spectrum of Activity Anaerobes – activity against upper airway anaerobes Atypical Bacteria – all macrolides have excellent activity against atypical bacteria including: . Legionella pneumophila – DOC* . Chlamydophila (psittacosis) and Chlamydia spp. . Mycoplasma spp. . Ureaplasma urealyticum Other Bacteria – Mycobacterium avium complex (MAC – only A and C), M. chelonae, M. marinum, Treponema pallidum, Campylobacter, H.pylori combination tx, Borrelia, Bordetella, Brucella, Pasteurella * = target organism

Macrolides Pharmacology

Absorption  Erythromycin – variable absorption (F = 15 to 45%); food may decrease the absorption . Base: destroyed by gastric acid; enteric coated . Esters and ester salts: more acid stable  Clarithromycin – acid stable and well- absorbed (F = 55%) regardless of presence of food  Azithromycin –acid stable; F = 37% regardless of presence of food

4 10/24/2012

Macrolides Pharmacology Distribution  Extensive tissue and cellular distribution – clarithromycin and azithromycin with extensive Vd’s  Minimal CSF penetration Elimination  Erythromycin is excreted in bile and metabolized (cyp450)  Clarithromycin is metabolized and also partially eliminated by the kidney (18% of parent and all metabolites); requires dose adjustment when CrCl < 30 ml/min  Azithromycin eliminated by biliary excretion  Variable elimination half-lives (1.4 hours for erythro; 3 to 7 hours for clarithro; 68 hours for azithro)  NONE of the macrolides are removed during hemodialysis!

Macrolides Clinical Uses • Respiratory Tract Infections  Pharyngitis/ Tonsillitis – pen-allergic patients  Sinusitis,COPD exaccerbation, Otitis Media (azithro best if H. influenzae suspected)  Community-acquired pneumonia – monotherapy in outpatients; with ceftriaxone for inpatients  With ceftriaxone for CABP for “anti- inflammatory effect”(J Antimicrob Chemother. 2005 Jan;55(1):10-21. Epub 2004 Dec 8).

Macrolides Clinical Uses (contd.) • Uncomplicated Skin Infections • STDs – Single 1 gram dose of azithro • MAC – Azithro for proph; Clarithro/ Azithro for RX

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Macrolides Clinical Uses

Alternative for Penicillin-Allergic Patients:  Group A Strep URIs  Prophylaxis of bacterial endocarditis  Syphilis and GC  Rheumatic fever prophylaxis  Currently, Strep.sp. and S. pneumoniae increasingly resistant to macrolides – so far not a problem for telithromycin (not marketed)

Macrolides Adverse Effects • Gastrointestinal – up to 33%  Nausea, vomiting, diarrhea, dyspepsia  Most common with erythro; less with new agents • Cholestatic hepatitis - rare  > 1 to 2 weeks of erythromycin estolate • Thrombophlebitis – IV Erythro and Azithro  Dilution of dose; slow administration • Allergic reactions.

Macrolides Adverse Effects • Prolonged QTc; aggravated by concomitant drugs that also prolong QTc (e.g. anti‐arrhythmics) • Exacerbation of myasthenia gravis (telithro/azithro) • Transient /reversible tinnitus or deafness •Drug‐drug: e.g., Colchicine: potentially fatal interaction.

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Macrolides Drug Interactions Erythromycin and Clarithromycin ONLY– are inhibitors of cytochrome p450 system in the liver and may increase concentrations of: Theophylline Digoxin, Disopyramide Carbamazepine Valproic acid Cyclosporine Terfenadine, Astemizole Phenytoin Cisapride Warfarin Ergot alkaloids NOT AZITHROMYCIN!!!

Macrolides versus Ketolides

C11-C12 Carbamate:  potency, overcomes O macrolide resistance O R Methoxy group: O  acid stability HO N HO OR OCH 11 O 11 3 12 6 12 6

O O Sugar O O Sugar

3 3 O Cladinose O O

Keto Group: Macrolides Ketolides  acid stability, overcomes macrolide resistance

Ketolides

• One agent approved = Telithromycin - Ketek® • Mechanism of action: inhibit protein synthesis  Bind to two domains (II & V) on the 50S ribosomal subunit; binds 10 times more strongly to domain II than the macrolides  May account for enhanced antimicrobial activity as well as superior activity against bacteria with erm- mediated (MLSB) resistance • Bacteriostatic • Resistance has been noted – ribosomal binding site alterations • In vitro activity against macrolide-resistant Streptococcus and Staphylococcus; poor activity against H. influenzae

7 10/24/2012

Telithromycin - Ketek • Pharmacology – PO only  Absorption: F = 57%, unaffected by food  Distribution: excellent into tissues and cells; protein binding = 60 to 70%  Elimination: metabolized by cytochrome p450 (3A4); half-life = 10 hours  No dose adjustment in renal insufficiency • Adverse effects – use has been limited  Gastrointestinal – diarrhea, hepatotoxicity  QTc prolongation  Decreased visual acuity, blurred vision

Telithromycin - Ketek

• Drug Interactions  Inhibitor of Cytochrome p450 3A4 – similar drug interactions as erythro and clarithro (digoxin, phenytoin, warfarin, cyclosporine) • Clinical Uses  Community-acquired pneumonia  Acute bacterial sinusitis  Acute exacerbations of chronic bronchitis

Streptogramins

• Synercid® is the first available streptogramin, which received FDA approval in September 1999 • Developed in response to the need for antibiotics with activity against resistant gram-positive bacteria, namely VRE • Synercid® is a combination of two semi- synthetic pristinamycin derivatives in a 30:70 w/w ratio: Quinupristin:Dalfopristin

8 10/24/2012

Synercid® Structure

Synercid®

Mechanism of Action • Each agent acts individually on 50S ribosomal subunits to inhibit early and late stages of protein synthesis • Binds on the 50S ribosome near where the macrolides and clindamycin bind • Bacteriostatic (may be bactericidal against some bacteria) Mechanisms of Resistance • Alterations in ribosomal binding sites (erm) • Enzymatic inactivation

Synercid® Spectrum of Activity

Gram-Positive Bacteria  Methicillin-Susceptible and Methicillin-Resistant Staph aureus and coagulase-negative staphylococci*  Streptococcus pneumoniae (including PRSP*), viridans streptococcus, Group streptococcus  Enterococcus faecium (including VRE)*  Corynebacterium, Bacillus. Listeria, Actinomyces  Clostridium spp. (except C. difficile), Peptococcus, Peptostreptococcus Gram-Negative Aerobes (not used here)  Limited activity against Neisseria sp. and Moraxella Atypical Bacteria (not used here)

 Mycoplasma, Legionella * = target organisms

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Synercid® Pharmacology

• Time-dependent bactericidal activity • PAE exists for Gram-Positive Bacteria  2 to 8 hours for S. aureus  8.5 hours for VSE; 0.2 to 3.2 hours for VRE • Absorption – only available parenterally • Distribution – penetrates into extravascular tissue, lung, skin/soft tissue; minimal CSF penetration • Elimination – both agents are metabolized; t½ is 0.6- 1 hour for quinu and 0.3 hours for dalfo

Synercid® Clinical Uses and Dosing

• Very expensive - ~ $350 per day • VRE (faecium) bacteremia (7.5 mg/kg Q8h) – 3rd line • Complicated skin and soft tissue infections due to MSSA or Streptococcus pyogenes (7.5 mg/kg Q12h) • Limited data in treatment of catheter- related bacteremia, infections due to MRSA, and community-acquired pneumonia (5 to 7.5 mg/kg Q8h)

Synercid® Drug Interactions

Cytochrome p450 3A4 Inhibitor

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Synercid® Adverse Effects

• Venous irritation – especially when administered through a peripheral vein • Gastrointestinal – nausea, vomiting, diarrhea • Myalgias, arthralgias – 2% •Rash

Clindamycin

Clindamycin is a semisynthetic derivative of lincomycin, isolated from Streptomyces lincolnesis in 1962. Clindamycin is absorbed better than other lincosamides and has a broader spectrum of activity.

Clindamycin

Mechanism of Action  Inhibits protein synthesis by binding exclusively to the 50S ribosomal subunit . Binds in close proximity to macrolides and Synercid– may cause competitive inhibition  Clindamycin typically displays bacteriostatic activity, but may be bactericidal when present at high concentrations against very susceptible organisms

11 10/24/2012

Clindamycin Mechanisms of Resistance  Altered target sites – encoded by the erm gene, which alters 50S ribosomal binding site; confers high level resistance to macrolides, clindamycin and Synercid (MLSb resistance)  Active efflux – mef gene encodes for an efflux pump that pumps macrolides out of the cell but NOT clindamycin; confers low level resistance to macrolides, but clindamycin still remains active

Clindamycin Spectrum of Activity

Gram-Positive Aerobes

Methicillin-susceptible Staphylococcus aureus* , and some CA-MRSA Streptococcus pneumoniae (only PSSP) – resistance is developing Group and viridans streptococci

* = target organism

Clindamycin Spectrum of Activity

Anaerobes – best activity against Above the Diaphragm Anaerobes (ADA)

Peptostreptococcus some Bacteroides spp* Actinomyces Prevotella spp. Propionibacterium Fusobacterium Clostridium spp. (not C. difficile)

Other Bacteria – Pneumocystis carinii, Toxoplasmosis gondii, Malaria * = target organism

12 10/24/2012

Clindamycin Pharmacology Absorption – available IV and PO  Rapidly and completely absorbed (F = 90%); food with minimal effect on absorption Distribution  Good serum concentrations with PO or IV  Good tissue penetration including bone; minimal CSF penetration Elimination  Clindamycin primarily metabolized by the liver (85%); enterohepatic cycling  Half-life is 2.5 to 3 hours  Clindamycin is NOT removed during hemodialysis

Clindamycin Clinical Uses

• Anaerobic Infections OUTSIDE of the CNS  Pulmonary, intraabdominal, pelvic, diabetic foot and decubitus ulcer infections • Skin & Soft Tissue Infections  Pen-allergic patients  Patients with infections due to CA-MRSA • Other  Alternative for C. perfringens, PCP, Toxoplasmosis, malaria, bacterial vaginosis

Clindamycin Adverse Effects • Gastrointestinal – 3 to 4% (esp with PO)  Nausea, vomiting, diarrhea, dyspepsia • Clostridium difficile colitis – one of worst inducers  Mild to severe diarrhea  Requires treatment with metronidazole or oral vancomycin • Hepatotoxicity - rare  Elevated transaminases • Allergy - rare

13 10/24/2012

Thank you!!

14 Pharmacology and Therapeutics Aminoglycosides October 30, 2012 Constance Pachucki, M.D.

#34 – AMINOGLYCOSIDES Drugs covered Amikacin, tobramycin, gentamycin, streptomycin

I. INTRODUCTION

The first group of antibiotics that are dosed individually for each patient and require serum concentration monitoring

II. MECHANISM OF ACTION

A. The mechanism of action of the aminoglycosides is multifactorial, but ultimately involves the inhibition of protein synthesis

B. Aminoglycosides irreversibly bind to the 30S ribosomal subunit (some to 50S subunits), which results in a disruption in the initiation of protein synthesis, a measurable decrease in protein synthesis, and misreading of messenger RNA.

1. The aminoglycosides must first bind to cell surface, not energy dependent

2. Transported across the bacterial cytoplasmic membrane by two energy dependent mechanism.

3. Ribosomal binding inhibits the synthesis of proteins, which disrupts the structure of the cytoplasmic membrane.

4. Aminoglycosides require aerobic energy to enter the cell and bind to ribosomes. (They are inactive against anaerobic bacteria)

C. Aminoglycoside antibiotics are rapidly bactericidal in a concentration- dependent manner, except against Enterococcus spp.

D. Post-antibiotic effect (PAE) 1. Suppression of bacterial growth after concentrations have fallen below MIC

2. Finite duration - 2 to 4 hours

3. Can dose every 24 hours

1 Pharmacology and Therapeutics Aminoglycosides October 30, 2012 Constance Pachucki, M.D.

III. MECHANISMS OF RESISTANCE

A. Alteration in aminoglycoside uptake

1. Chromosomal mutations that influence any part of the binding and/or electrochemical gradient that facilitates aminoglycoside uptake – leads to decreased penetration of aminoglycoside inside the bacteria.

B. Synthesis of aminoglycoside-modifying enzymes

1. Plasmid-mediated resistance factor that enables the resistant bacteria (usually gram-negative) to enzymatically modify the aminoglycoside by acetylation, phosphorylation, or adenylation. The modified aminoglycoside displays poor uptake and binds poorly to ribosomes, leading to high-level resistance.

2. A large number of enzymes have been identified, and cross-resistance may occur. Gentamicin and tobramycin are generally susceptible to the same modifying enzymes, while amikacin is resistant to many enzymes.

C. Alteration in ribosomal binding sites

1. Ribosomal binding site alterations rarely occur as a mechanism of resistance to gentamicin, tobramycin, and amikacin.

IV. SPECTRUM OF ACTIVITY

A. Gram-negative aerobes

1. Enterics E. coli, K. pneumoniae, Proteus spp. Acinetobacter, Citrobacter, Enterobacter spp. Morganella, Providencia, Serratia, Salmonella, Shigella)

2. Pseudomonas aeruginosa

B. Mycobacteria

1. Tuberculosis – streptomycin

2. Non-tuberculous mycobacteria - streptomycin or amikacin

C. Not active against anaerobes

2 Pharmacology and Therapeutics Aminoglycosides October 30, 2012 Constance Pachucki, M.D.

D. Gram-positive aerobes: (NEVER USED ALONE, are used with cell-wall active agents to provide synergy; LOW DOSES) – primarily gentamicin

Most strains of S. aureus and coagulase-negative staphylococci Viridans streptococci Enterococcus spp. (gentamicin or streptomycin)

E. Synergy

1. Synergy exists between the aminoglycosides and cell-wall active agents, such as -lactams and vancomycin. Synergy is demonstrated when the effect of the drugs in combination is greater than the anticipated results based on the effect of each individual drug; the effects are more than additive.

2. Possibly due to enhanced uptake of aminoglycoside into bacteria whose cell walls have been damaged by cell wall synthesis inhibitors.

3. Synergy has been demonstrated for:

Enterococcus - with ampicillin, penicillin or vancomycin (gent or strep) S. aureus, viridans streptococci- with -lactams or vancomycin (gent) P. aeruginosa and other gram-negative aerobes - with -lactams (gent- amicin, tobramycin or amikacin)

V. PHARMACOLOGY

A. Absorption 1. Aminoglycosides are very poorly absorbed from the gastrointestinal tract.

2. Aminoglycosides are well absorbed after IM administration, Rarely used.

3. Intermittent intravenous infusion is the preferred route of administration, B. Elimination

1. 85 to 95% of an administered aminoglycoside dose is eliminated unchanged by the kidney via glomerular filtration, resulting in high urinary concentrations.

VII. CLINICAL USES

A. Largely replaced by Beta-lactam antibiotic

3 Pharmacology and Therapeutics Aminoglycosides October 30, 2012 Constance Pachucki, M.D.

B. Aminoglycosides are toxic and require monitoring of serum levels

C. RARELY USED AS MONOTHERAPY

1. Used in combination with beta-lactam to treat pseudomonas aeruginosa and other highly resistant gram negative bacilli

D. Urinary tract infections, sepsis especially urinary source or intra-abdominal source, skin and soft tissue infections,

1. Does not penetrate into lung, so cannot be used alone for pneumonia

E. Amikacin

1. Used for gram negative infections with multi-drug resistance

2 Least likely to be inactivated by bacterial resistance enzymes

F. Gentamicin or streptomycin

1. used for synergy with appropriate cell wall active agents (ampicillin, vancomycin, etc) for the treatment of serious infections (endocarditis) due to enterococci, viridans streptococci, or staphylococci.

G. Streptomycin is used in conjunction with other antituberculous medications

VIII. ADVERSE EFFECTS

A. Nephrotoxicity

1. Manifested as nonoliguric azotemia secondary to proximal tubular damage, leading to an increase in BUN and serum creatinine.

2. Reversible if the aminoglycoside dose is adjusted or the drug is discontinued early enough.

3. The risk factors for the development of nephrotoxicity include prolonged high trough concentrations, prolonged therapy > 2 weeks, the presence of underlying renal insufficiency, advanced age, hypovolemia, and the use of concomitant nephrotoxins (vancomycin, amphotericin B, cisplatin, CT contrast, etc.).

4. Comparative nephrotoxicity-gentamicin most nephrotoxic

4 Pharmacology and Therapeutics Aminoglycosides October 30, 2012 Constance Pachucki, M.D.

a. Gent>tobra>amikacin>streptomycin

B. Ototoxicity - auditory and vestibular

1. Due to eighth cranial nerve damage.

a. Damage is irreversible, and must be caught early.

b. Vestibular symptoms include dizziness, nystagmus, vertigo and ataxia

c. Auditory toxicity tinnitus, hearing loss

2. Auditory toxicity is more common with amikacin>gentamicin and tobramycin

3. Vestibular toxicity is more common with streptomycin>gentamicin, or tobramycin>amikacin.

4. The risk factors for the development of ototoxicity include prolonged high trough concentrations, prolonged therapy > 2 weeks, the presence of renal insufficiency, advanced age, and the concomitant use of other ototoxic drugs(vancomycin, loop diuretics).

C. Other rare adverse effects of the aminoglycosides include neuromuscular blockade

5 Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin and November 1, 2012 Oral Anticoagulants.

TREATMENT OF THROMBOSIS: HEPARIN, LOW MOLECULAR WEIGHT HEPARIN AND ORAL ANTICOAGULANTS

Date: November 1, 2012-9:30 am Reading Assignment: Katzung 12th Ed., pp. 604-611

KEY CONCEPTS & LEARNING OBJECTIVES

1. To define the major classes of anticoagulant drugs with reference to their mechanism of action. 2. To describe the mechanism of the anticoagulant action of heparin with particular reference to its interaction with antithrombin. 3. To define the mechanism of protamine neutralization of heparin and to calculate the amount of protamine needed for the neutralization of the action of a given amount of heparin. 4. To know the differences between heparin and low molecular weight heparins. 5. To know the currently approved indications for low molecular weight heparins. 6. To understand the rationale of the use of low molecular weight heparins in the treatment of acute coronary syndromes and venous thrombosis. 7. To describe the laboratory tests needed for monitoring the actions of heparin. 8. To define the mechanism of anticoagulant action of the antithrombin agents and how it differs from heparin and low molecular weight heparin. 9. To understand the rationale for the use of direct thrombin inhibitors in the management of heparin induced thrombocytopenia. 10. To understand the mechanism of heparin-induced thrombocytopenia 11. To define the mechanism of action of oral anticoagulant drugs with particular reference to the role of -carboxylation of glutamic acid. 12. To describe major drug interactions with oral anticoagulant drugs. 13. To identify the role of vitamin K in the synthesis of coagulation factors II, VII, IX and X. 14. To describe the laboratory tests needed for monitoring the actions of oral anticoagulants. 15. To know the main clinical use of oral anticoagulant drugs. 16. To describe the mechanism of action of the new oral anticoagulants (dabigatran, apixaban and rivaroxaban).

LIST OF DRUGS COVERED IN LECTURE

1 Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin and November 1, 2012 Oral Anticoagulants.

A. Heparin (systemic anticoagulant) B. Low molecular weight heparin (enoxaparin, dalteparin, tinzaparin) C. Generic Enoxaparin D. Pentasaccharide (Arixtra®) E. Danaparoid (Orgaran®) F. Protamine sulfate G. Antithrombin-III H. Hirudin (Refludan®) I. Argatroban (Novastan®, Acova) J. Bivalirudin (Angiomax®) K. Warfarin (oral anticoagulant). L. Vitamin K M. Fresh frozen plasma N. Anti-Xa agents- Rivaroxaban, Apixaban O. Anti-IIa agents- Dabigatran

ALTERNATIVE THERAPIES

A. Compression devises B. TED (Thromboembolic Deterrent) stockings C. Foot Pump D. Exercise

2 Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin November 1, 2012 and Oral Anticoagulants D. Moorman., Ph.D. TREATMENT OF THROMBOSIS: Heparin, Low Molecular Weight Heparin and Oral Anticoagulants

I. ANTICOAGULANT DRUGS . A. Introduction. Drugs used to anticoagulate blood for the treatment of thrombosis and for surgical indications.

B. Heparin: 1. Naturally occurring anticoagulant found in the granules of mast cells along with histamine and serotonin. 2. Chemistry: Heparin is a strongly acidic (highly ionized) mucopolysaccharide composed of repeating units of sulfated glucuronic acid and sulfated glucosamine.

MOLECULAR HETEROGENEITY IN HEPARIN (Heparin is composed of high molecular weight and low molecular weight components)

From: Fareed et al, 1989. Chemical and Biological Heterogeneity in Low Molecular Weight Heparins: Implications for Clinical Use and Standardization. Seminars in Hemostasis Thrombosis, 15(4): 440-463.

a. Heparin's composition varies in molecular weight constituents (2,000 - 40,000 DA)

1 Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin November 1, 2012 and Oral Anticoagulants D. Moorman., Ph.D.

Heparin is composed of sulfated polysaccharide chains which vary in length (15-50 hexose units). These chains also exhibit different behaviors and interact with blood vessels and cells.

CHEMICAL STRUCTURE OF A HEPARIN OLIGOSACCHARIDE UNIT

Refer to Figure 34-4 in Katzung, 10th Edition, pg. 547.

3. Source:

a. Extracted from tissues rich in mast cells (beef lung and porcine intestine).

4. Biological standardization:

a. Because of variability in its molecular composition heparin is assayed and compared to a USP reference standard in pooled citrated sheep plasma to which Ca+2 has been added. b. 1 mg of heparin should be equivalent to at least 120 USP units (10 g = 1 unit).

5. Actions of heparin:

a. Inhibits the action of activated factor Xa and factor IIa (Thrombin). b. Inhibits the action of several other serine protease enzymes (XIIa, XIa). c. Inhibits the aggregation of platelets (at high concentration). d. Plasma clearing effect: turbid plasma is rapidly cleared of fat chylomicrons by a release of lipase from the blood vessels. e. Binds to vascular lining and neutralizes the positive charge. f. Causes a release of tissue factor pathway inhibitor (TFPI).

6. Heparin preparations:

a. Mucosal heparin - sheep (rarely used) - porcine (derived from pig intestine) b. Lung heparin

2 Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

- Mostly bovine preparations, used in cardiac surgery

c. Different salts of heparin (Na+, Ca+2 ) d. Low molecular weight heparins -Enoxaparin®, Fragmin®, Ardeparin® and Tinzaparin® e. Synthetic heparin (Heparin pentasaccharide) Arixtra®

7. Route of administration and therapeutic monitoring:

a. Intravenous and Subcutaneous b. Not absorbed via oral or rectal route. Heparin is highly charged at all pH's. Special formulations of heparin are developed for oral use. c. There is a poor correlation between the dose of heparin and weight of the patient. The anticoagulant effect is carefully monitored using the APTT method to determine the dose.

8. Metabolism:

a. 20-25% of heparin is excreted in urine b. Some heparin is picked up by mast cells c. Endothelium is able to bind heparin d. Metabolized in liver by heparinase into small components

9. Duration of action:

a. Biologic T½ of intravenous heparin is l-3 hours, depending on the dose. Onset of action is 5-10 minutes (as measured by APTT method).

10. Endogenous modulators of heparin action:

a. AT (main heparin co-factor) b. Heparin cofactor II (second cofactor) c. Tissue factor pathway inhibitor (TFPI) d. Platelet factor 4 (heparin neutralizing protein)

11. Side effects of heparin:

a. Hemorrhagic complications Adrenal, gut, etc. b. Heparin induced thrombocytopenia and heparin induced thrombosis - Generation of antiheparin platelet factor 4 antibodies. These antibodies activate platelets and endothelial cells. c. Osteoporotic manifestation with spontaneous fracture following chronic administration and large doses

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

d. Alopecia (loss of hair) Long-term usage

12. Clinical use of heparin:

a. Therapeutic anticoagulation b. Surgical anticoagulation c. Prophylactic anticoagulation d. Unstable angina and related coronary syndromes e. Adjunct therapy with thrombolytic drugs f. Thrombotic and ischemic stroke

13. Protamine sulfate and heparin neutralization:

a. Protamine is a powerful heparin antagonist. It has a low molecular weight and is a highly basic protein found in the sperm of certain fish. b. It combines with strongly acidic heparin to form a stable salt with loss of anticoagulant activity. c. Available as a 1% solution and generally used on a weight basis. d. One USP unit of heparin is neutralized by 10 g of protamine (2500 units of heparin is neutralized by 25 mg of protamine).

e. Intravenous injection of protamine may cause the following:

Fall in blood pressure

Bradycardia

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

II. LOW MOLECULAR WEIGHT HEPARINS & SYNTHETIC HEPARIN PENTASACCHARIDE

1.

From: Fareed et al, 1989. Chemical and Biological Heterogeneity in Low Molecular Weight Heparins: Implications for Clinical Use and Standardization. Seminars in Hemostasis Thrombosis, 15(4): 440-463.

5

Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

Structure of Chemically Synthesized Heparin Pentasaccharides

Heteogeneity in Low Molecular Weight Heparins: Implications for Clinical Use and Standardization. Seminarrs in Hemostasis Thrombosis, 15(4):440-463, 1993

2. Bioavailability of low molecular weight heparins in % bioavailability after subcutaneous administration. - Low molecular weight heparins are bioavailable at 100% whereas heparin has a limited bioavailability (<30%)

From: Fareed et al, 1989. Chemical and Biological Heterogeneity in Low Molecular Weight Heparins: Implications for Clinical Use and Standardization. Seminars in Hemostasis Thrombosis, 15(4): 440-463.

3. Clinical advantages of low molecular weight heparins:

a. Better bioavailability b. Longer duration of action c. Less bleeding d. Lesser thrombocytopenia

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

4. Clinical use:

a. Prophylaxis of DVT b. Treatment of DVT c. Management of acute coronary syndromes d. Other uses such as anticoagulation for surgical and interventional cardiovascular procedures

III. GENERIC ENOXAPARIN

1. Sandoz Enoxaparin 2. Amphastar Enoxaparin

IV. ANTITHROMBIN – CONCENTRATES (AT):

1. Antithrombin-concentrate is prepared by using heparin-sepharose affinity chromatography. This concentrate is used to treat patients with acquired or congenital antithrombin- deficiency. AT is also useful in sepsis and disseminated intravascular coagulation. 2. Available as a plasma-derived concentrate in batches of 500 units 3. Can be used for patients with hypercoagulable states

V. DIRECT ANTITHROMBIN AGENTS:

Hirudin is a protein from the saliva of the medicinal leech (Hirudo medicinalis) which contains several pharmacologically active substances. Using recombinant technology recombinant forms of this drug are produced. Currently r-hirudin is used in the anticoagulant management of heparin induced thrombocytopenic patients. A commercial preparation, namely, refludan (Pharmion) is available for clinical use.

Argatroban is a synthetic antithrombin agent which is currently used as an anticoagulant in patients who can not be treated with heparin, special usage in the management of heparin induced thrombocytopenia.

Bivalirudin (Angiomax®) is a synthetic antithrombin agent. This agent is a hybrid molecule between a component of hirudin and a tripeptide. This drug is approved for PTCA anticoagulation.

PROPHYLAXIS AND TREATMENT OF THROMBOSIS: ORAL ANTICOAGULANTS

I. Warfarin and the coumarin anticoagulants:

1. Only the coumarin derivatives are used in the U.S. The warfarin, (Coumadin®), brand of oral anticoagulant is most widely prescribed.

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

2. Prophylactic use: Prevention of thrombotic disorders 3. Therapeutic use: Treatment of established thrombus

Integrated Coagulation Cascade and Its Modulation by Anticoagulant Drugs.

Refer to Katzung 10th Edition, Figure 34-2, page 544.

Chemical structure of oral anticoagulants structurally similar to vitamin K (analogues).

8

Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

Refer to Katzung 10th Edition, Figure 34-5, pg. 550.

Mechanism of action

All agents depress the formation of functional forms of factors II (prothrombin), VII, IX and X by inhibiting the carboxylation of glutamic acid in these proteins which is essential for Ca+2 binding.

Refer to Katzung, 10th Edition, Figure 34-6, pg. 550.

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

Refer to Katzung, 8th Edition, Figure 34-7, pg. 571.

II. Dose:

1st day: 5 - 10 mg/d (Initial dosing).

2nd day: 5 - 7 mg/d (maintenance).

III. Route of administration:

All are well absorbed orally

IV. Fate:

Long T½ of the oral anticoagulants, due to binding to plasma albumin (warfarin is about 97% bound).

V. Metabolism:

1. Dicumarol and warfarin are hydroxylated to inactive compounds by the hepatic endoplasmic reticulum. 2. Metabolism varies greatly in patients.

VI. Therapeutic monitoring of oral anticoagulant drugs:

1. Warfarin depresses the functionality of vitamin K dependent factors (II, VII, IX and X). Thus, it impairs the blood coagulation in the extrinsic pathway. Prothrombin time (PT) is used to monitor the anticoagulant effects of warfarin. 2. A 1.5 time prolongation of the PT from the baseline is considered to be therapeutic. For example, if a patient's baseline PT is 12 seconds, he is considered in the therapeutic range around 18 seconds. 3. A patient with a lesser prolongation than 1.5 times the baseline is subtherapeutic and a dose increase may be necessary. 4. Reagent based variations have been noted in the prothrombin time. To obtain uniform degrees of anticoagulation, the concept of international normalized ratio (INR) has been introduced.

INR = PT (sec) patient ISI PT (sec) mean normal control

The INR can be used universally to adjust the level of anticoagulant in a given patient. Thus it helps in the optimization of dosage.

VII. Control of dose:

Many factors affect the dose of the oral anticoagulants.

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Pharmacology & Therapeutics Prophylaxis & Treatment of Thrombus: Oral Anticoagulants November 1, 2012 D. Moorman, Ph.D

1. Nutrition 2. Anemia 3. Liver disease 4. Biliary obstruction 5. Drugs

VIII. Drug interactions with warfarin:

1. Drugs cause warfarin potentiation:

a. by causing vitamin K deficiency. b. by displacing warfarin from protein binding sites. c. by decreasing clotting-factor synthesis d. by suppressing or competing for microsomal enzymes. e. by having antiplatelet aggregating properties.

2. Drugs reported to cause inhibition of the anticoagulant action of warfarin:

a. by decreasing warfarin absorption.

b. by enhancing warfarin metabolism.

Refer to Katzung 10th Edition, Table 34-2, pg. 551

. IX. Toxicity of Warfarin:

1. Principal toxicity is a marked hypoprothrombinemia resulting in ecchymosis, purpura, hematuria, hemorrhage.

2. All oral anticoagulants pass the placental barrier and may cause fetal malformation.

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Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin and November 1, 2012 Oral Anticoagulants D. Moorman

3. Warfarin also produces necrosis (Coumadin® induced necrosis). This is basically due to the impairment of the functionality of protein C. This protein also requires - carboxylation of glutamic acid for functionality.

4. Treatment of oral anticoagulant overdose.

a. Replacement of 4 factors. Infusion of whole fresh blood or frozen plasma. b. Recombinant factor VIIa c. Vitamin K

X. Vitamin K:

1. Naturally occurring fat-soluble vitamin found in green vegetables and synthesized by gut flora. These agents are structurally similar to the oral anticoagulants.

2. Function of vitamin K:

a. Essential to the attachment of a calcium binding functional group to prothrombin protein (presence of -carboxyglutamic acid). b. Required for the synthesis of clottable coagulation factors (II, VII, IX and X).

3. Therapeutic use:

a. Drug induced hypoprothrombinemia - antidote. b. Intestinal disorders and surgery (gastrectomy). c. Hypoprothrombinemias of newborn.

4. Toxicity - remarkably non-toxic:

High doses sometimes cause hemolysis in infants (mainly water soluble vitamin K).

XI. New Oral Anticoagulants*

1. Anti-Xa agents

a. Rivaroxaban (Xarelto) b. Apixaban

2. Antithrombin agents

a. Dabigatran

12 Pharmacology & Therapeutics Treatment of Thrombosis: Heparin, Low Molecular Weight Heparin and November 1, 2012 Oral Anticoagulants D. Moorman

Heparin & Low Molecular Weight Heparins Important Points to Remember

DRUG MECHANISM OF ROUTE OF ADMINISTRATION INDICATIONS SIDE EFFECTS ACTION Heparin Complex with AT and Mainly intravenous and also Surgical Anticoagulation Bleeding, HIT, inhibits factors Xa and given subcutaneous osteoporosis, alopecia IIa, Monitored by APTT Low Molecular Complex with AT and Mainly subcutaneous Prophylaxis and Treatment Bleeding Weight Heparins inhibits factors Xa and of DVT and ACS IIa Fondaparinux Complex with AT and Subcutaneous Management of DVT Bleeding (Pentasaccharide) inhibits factor Xa Argatroban Inhibits IIa Intravenous Anticoagulant management Bleeding of HIT patients Inhibits IIa Intravenous Anticoagulant management Bleeding Bivalirudin of HIT patients Inhibits IIa Intravenous Anticoagulant management Bleeding Hirudin of HIT patients Inhibits IIa Intravenous DIC, sepsis, thrombophilia, None Antithrombin hypercoagulable state Concentrate Protamine Sulfate Heparin antagonist Intravenous Reversal for Heparin Bradycardia, hypotens

Oral Anticoagulants Important Points to Remember

DRUG MECHANISM OF ACTION MONITORING INDICATIONS SIDE EFFECTS/ TOXICITY Warfarin Competitive antagonist of Prothrombin time/INR Prolonged treatment of Bleeding, coumadin vitamin K. Suppresses the DVT and Atrial induced necrosis synthesis of functional forms Fibrillation of factors II, VII, IX and X Vitamin K Cofactor in the synthesis of Not Required Hypoprothrombinemia, Hemolysis, functional forms of factors II, intestinal disorders and VII, IX and X, reverses gastrectomy warfarins effects Oral Anti-Xa Inhibits factor Xa Not Required Prophylaxis of DVT, Bleeding, liver toxicity - Rivaroxaban atrial fibrillation in the - Apixaban prevention of stroke

Oral Antithrombin Inhibits thrombin Not Required Prophylaxis of DVT, Bleeding, liver toxicity - Dabigatran atrial fibrillation in the prevention of stroke

13 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph.D.

ANTIPLATELET DRUGS

Date: November 2, 2011 8:30 am Reading Assignment: Katzung 12th Ed., pp. 612-614 Katzung and Trevor’s Pharmacology, Examination & Board Review.8th Ed., pp. 157-162, pp. 286-287.

KEY CONCEPTS & LEARNING OBJECTIVES

1. To know the major antiplatelet drugs and their site of actions. 2. To describe the mechanism of action of aspirin and related inhibitors of cyclooxygenase. 3. To understand the mechanism of action of ADP receptor inhibitors (P2Y12), clopidogrel (Plavix®), Prasugrel (Effient) and Ticagrelor (Brilinta). 4. To know the use of antiplatelet drugs for the treatment of arterial thrombosis. 5. To know the mechanisms of action of the glycoprotein IIb/IIIa inhibitors (GPIIb/IIIa inhibitors). 6. To know the mechanism of the antiplatelet action of omega-3 fatty acids. 7. To understand the rationale of antiplatelet therapy used in the management of acute coronary syndromes. 8. To describe the laboratory tests useful in the monitoring of antiplatelet drugs. 9. To know the drug interactions between antiplatelet agents and other anticoagulant drugs

2 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph.D.

LIST OF DRUGS COVERED IN LECTURE:

1. Aspirin . 2. Ticlopidine (Ticlid®) 3. Clopidogrel (Plavix®) 4. Prasugrel (Effient) 5. Ticagrelor (Brilinta) 6. Dipyridamole (Persantine®) 7. Cilostazol (Pletal®) 8. Abciximab (ReoPro®) 9. Tirofiban (Aggrastat®) 10. Eptifibatide (Integrilin®) 11. Celebrex® (COX-2 inhibitor) 12. Vioxx® (COX-2 inhibitor) 13. Bextra® (COX-2 inhibitor) 14. Propionic acid derivatives (Ibuprofen) 15. Cangrelor (in development for IV use)

ALTERNATIVE THERAPIES

1. Fish oil emulsions 2. Gingko products 3. Garlic extracts 4. Soy products

2 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph. D.

ANTIPLATELET DRUGS

I. Pharmacology of platelet aggregation:

During platelet release reactions many pharmacologically active substances are secreted from the dense (Beta) and light (alpha) granules. In addition, many of the prostaglandin derivatives such as thromboxanes are formed. All of these substances exert a profound action on the overall function of platelets.

1. Light (alpha) granule release products:

a. Platelet factor 4

b. Beta-thromboglobulin

c. Platelet-derived growth factor (PDGF)

2. Dark (Beta) granule release products:

a. Ca+2

b. Serotonin (5-Hydroxytryptamine)

c. ATP/ADP

3. Products formed during platelet activation and endothelium interaction: prostaglandin derivatives, endoperoxides, thromboxanes.

II. Antiplatelet agents:

Antiplatelet agents - decrease platelet aggregation primarily in the arterial system.

1. Aspirin - antipyretic analgesic, decreased platelet aggregation, prolongs bleeding.

2. ADP Receptor inhibitors-Ticlopidine (Ticlid), Clopidogrel (Plavix) , Prasugrel (Effient) and Ticagrelor (Brilinta).

3. Propionic acid derivatives (NSAIDs)- Analgesic agents (also exhibit antiplatelet effects).

4. Dipyridamole (Persantine®)-a coronary vasodilator

5. Cilostazol (Pletal®) - a new drug for the management of intermittent claudication

6. GPIIb/IIIa Inhibitors (ReoPro®, Aggrastat® and Integrilin®)

1 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph. D.

7. Prostacyclin analogue (Iloprost®) and thromboxane receptor antagonists

8. Cyclooxygenase (COX) inhibitors (COX 1 and COX 2 inhibitors), Celebrex®, Vioxx® and Bextra

Platelet

GP IIb/IIIa

Tirofiban Aspirin, NSAIDs Eptifibatide Prasugrel Abciximab Ticagrelor Collagen Clopidogre Ticlopidine Cyclooxygenase-1 AA PGG2, PGH2 GP Ia/IIa TxA2 ADP PAR-1, Synthase TxA PAR-4 2 Fc?RIIa GPIb Thrombin cAMP AMP PGI2 5HT2 Receptor Phosphodiesterase Thromboxane receptor PDEI Serotonin TXRI

JF,WJ 2008

9. Anti-platelet drug combinations

a. Aspirin/clopidogrel, aspirin/prasugrel, aspirin/ticagrelor

b. Aspirin/GP IIb/IIIa inhibitor

c. Anticoagulant/antiplatelet drugs

d. Antiplatelet/thrombolytic drugs

e. Dipyridamole/aspirin

III. Clinical applications of antiplatelet drugs:

1. Cerebrovascular disease:

a. Transient ischemic attack (TIA)

2 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph. D.

b. Complete stroke

c. Carotid endarterectomy

d. Geriatric patients (institutionalized)

2. Coronary artery disease:

a. Acute myocardial infarction

b. Unstable angina

3. Saphenous vein coronary artery bypass grafts:

4. Peripheral vascular disease:

a. Venous thrombosis

b. Peripheral arterial disease (PAOD, intermittent claudication)

5. Small vessel disease:

a. Membrane proliferative glomerulonephritis

b. Thrombotic thrombocytopenic purpura

c. Other syndromes

6. Prevention of thrombus formation on artificial surfaces

IV. Drug interactions with antiplatelet agents:

1. Thrombolytic agents (urokinase, streptokinase and tissue plasminogen activator).

2. Heparin/LMW heparin/oral anticoagulants

3. Warfarin

4. Antithrombin agents (hirudin, bivalirudin and argatroban)

3 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph. D.

V. Pathways of Arachidonic Acid Release and Metabolism:

Refer to Katzung 11th Edition, Figure 18-1.

Arachidonic acid is metabolized by two major pathways:

1. Cyclooxygenase pathway

2. Lipoxygenase pathway

Both of these pathways and the epoxygenase(s) result in the formation of potent pharmacologic substances that can produce various pathophysiologic and physiologic responses. The products of the cyclooxygenase and lipoxygenase pathways produce different effects on blood vessels and blood cells. These include the following:

a. Vasoconstriction and vasodilation

b. Platelet aggregation and disaggregation

c. Leukocyte activation

4 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 J. Fareed, Ph. D.

d. Target site effects

VI. Cyclooxygenase Pathway: Refer to Katzung 11th Edition, Figure 18-2.

Aspirin inhibits both COX-1 and COX-2 thereby limiting the production of prostaglandins. In particular thromboxane formation in platelets is inhibited. This is the main mechanism by which aspirin mediates its therapeutic effects.

1. Regulation of prostacyclin and thromboxane synthesis.

a. Endothelial lining

b. Lipoproteins and other blood components

c. Diet

d. Drugs

5 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 Jawed Fareed, Ph. D.

e. Hemodynamic factors

GENERATION OF ARACHIDONIC ACID METABOLITES AND THEIR ROLES IN INFLAMMATION & THROMBOSIS

Kumar et al, p.37, Basic Pathology, 199.

VII. Pharmacology of Fish Oil

1. Active ingredients (omega-3 fatty acid).

a. -linolenic acid

b. eicosapentaenoic acid

c. docosahexaenoic acid

2. Mechanism of antiplatelet action.

a. Membrane effects.

b. Thromboxane A3 (inactive) formation

6 Pharmacology & Therapeutics Antiplatelet Drugs November 2, 2012 Jawed Fareed, Ph. D.

Antiplatelet Drugs Important Points to Remember

DRUG MECHANISM OF ROUTE OF INDICATIONS SIDE EFFECTS ACTION ADMINISTRATION

Aspirin COX Oral ACS, stroke,arterial thrombosis Bleeding, gastric irritatio Inhibitors Clopidogrel ADP receptor inhibitor Oral ACS, stroke, in stent Bleeding,TTP thrombosis Prasugrel ADP receptor Inhibitor Oral ACS, stroke, in stent, Bleeding thrombosis NSAIDS COX inhibitor Oral Various diseases Bleeding

Dipyridamole Phosphodiesterase Oral Arterial thrombosis/stroke Bleeding Inhibitor Cilostazol Phosphodiesterase Oral Intermittent claudication Hypotension Inhibitor Abciximab GP IIb/IIIa inhibitor Intravenous ACS/PCI Bleeding

Eptifibatide GP IIb/IIIa inhibitor Intravenous ACS/PCI Bleeding

Tirofiban GP IIb/IIIa inhibitor Intravenous ACS/PCI Bleeding

Ticagrelor ADP receptor inhibitor Oral ACS, stroke, in stent, Bleeding thrombosis

7 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D.

PHARMACOLOGY OF THROMBOLYTIC AGENTS

Date: November 2, 2012-9:30 am Reading Assignment: Katzung, B.G., 12th Ed., pp.611-612.

KEY CONCEPTS AND LEARNING OBJECTIVES

1. To know the different components of the fibrinolytic system in terms of inhibitors, activators and zymogens. 2. To distinguish between the plasmin mediated degradation of fibrinogen and fibrin. 3. To know the role of plasminogen in fibrinolysis. 4. To know the physiologic activators of plasminogen with particular reference to the role of endothelial t-PA in physiologic thrombolysis. 5. To know the site of action of different thrombolytic agents. 6. To describe the side effects of thrombolytic therapy. 7. To know the antagonists that can be used for neutralizing the actions of thrombolytic agents. 8. To know the possible interactions of thrombolytic agents with aspirin and heparin 9. To know which laboratory tests can be used for the monitoring of thrombolytic agents.

LIST OF DRUGS COVERED IN LECTURE:

1. Urokinase 2. Streptokinase 3. Streptokinase Plasminogen Complex (Anistreplase, Eminase) 4. Tissue plasminogen activators (Alteplase, Reteplase, Tenecteplase) 5. Pro-urokinase 6. Epsilon amino caproic acid 7. Tranexamic acid 8. Ancrod 9. Aprotinin

ALTERNATIVE THERAPIES

1. Atherectomy 2. Stents 3. Rotoablation

1 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

PHARMACOLOGY OF THROMBOLYTIC AGENTS

I. INTRODUCTION TO FIBRINOLYTIC PROCESSES

Plasminogen Activators

Urokinase-type Liver Tissue-type Vascular endothelium Contact activation system

Plasminogen Plasmin

Inhibitors Plasmin activator

A. Activation and Inhibition of Blood Fibrinolytic System

Refer to Katzung 11th Edition Figure 34-3, pg. 590.

1 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

The fibrinolytic system is regulated by a variety of activators and inhibitors. A balance between the activators and inhibitors is important.

1. Physiologic Activators:

a. t-PA I Single chain tissue plasminogen activator

b. t-PA II Two chain tissue plasminogen activator

c. Pro Urokinase (SCUPA: Single chain urinary plasminogen activator)

d. Urokinase

The physiologic activators of plasminogen are able to convert endogenous plasminogen into plasmin. This action plays a key role in the dissolution of clots which are formed due to coagulation activation.

2. Physiologic Inhibitors:

a. PA-I Rapid-acting plasminogen activator inhibitor.

b. Thrombin activatable fibrinolytic inhibitor (TAFI)

c. lpha 2 - antiplasmin

d. lpha 2 - macroglobulin

e. C1 - esterase inhibitor

B. Physiologic Regulation of Fibrinolysis:

1. Molecular components:

a. Activators and inhibitors

b. Plasminogen (Pro-fibrinolysin)

Zymogenic form of the active enzyme plasmin single chain molecule (Mol. Wt. 88,000 Da). Composed of 790 amino acids. Native form is known as Glu-plasminogen. Plasmin cleaves the initial terminal 76 amino acids to form Lys-plasminogen.

2 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

c. Plasmin (Fibrinolysin)

Active protease capable of digesting both fibrinogen and fibrin. Formed by the cleavage of the Arg 560-Val bond by plasminogen activators.

C. Degradation of Fibrinogen and Fibrin by Plasmin

1. Fibrinogen can be degraded by plasmin:

FORMATION OF F.D.P.'S

A-ALPHA B-BETA FIBRINOGEN GAMMA D E D

FRAGMENT X + B Beta 1-42, A alpha fragments D E D

FRAGMENT D FRAGMENT Y

FRAGMENT E FRAGMENT D

Fragments X, Y, D and E are formed by the digestion of fibrinogen.

3 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

2. Fibrin:

Fibrin is formed by the action of thrombin on fibrinogen. Formed fibrin strands are stabilized by the action of Factor XIIIa. Plasmin acts on stabilized fibrin to form various products such as the DD/E, YD/DY and YY/E.

Fragments DDE, YD/DY and YYDD are formed by the action of plasmin on polymerized fibrin monomers (clots).

JF/RB, 2004.

Fragments DDE, YD/DY and YYDD are formed by the action of plasmin on polymerized fibrin monomers (clots).

D. Physiologic Control of Thrombolysis:

Several factors control physiologic fibrinolysis.

1. Factors that promote fibrinolysis:

a. Plasminogen incorporation into thrombus via fibrin binding

b. Clot retraction

c. Local release of t-PA by endothelial cells

d. Binding of t-PA to fibrin

e. Enhanced t-PA or UK activity in the presence of fibrin

f. Protection of bound plasmin from antiplasmin

4 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

2. Factors Which Limit Fibrinolysis:

a. Fibrin crosslinking by Factor XIIIa

b. Binding of alpha2-antiplasmin to fibrin

c. Low ratio of endothelial surface to thrombus volume in large vessels

d. Efficient inhibition of free plasmin by antiplasmin

e. Antiplasmin impairs plasmin binding to fibrin.

E. Fibrinolytic Balance: Thrombosis vs. Bleeding

An intricate balance in the fibrinolytic process maintains the blood in the fluid state. Either thrombotic or bleeding complications can result if the balance is not maintained.

II. THROMBOLYTIC THERAPY

A. Introduction:

Comprised mainly of plasminogen activators. Several thrombolytic agents are now clinically used for the dissolution of clots (thrombi). Degradation of clots produce the following effects:

1. Reduction in thrombus size (thrombolytic)

2. Reduction of fibrinogen levels

3. Increase in the fibrinogen and fibrin degradation products

4. Antiplatelet activators

B. Classification of Thrombolytic Agents:

The thrombolytic agents can be classified according to their development and clinical usage.

1. Clinically approved thrombolytic agents

a. Urokinase-Approved in Canada and Europe

b. Streptokinase

c. Recombinant tissue plasminogen activators

5 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

- Alteplase (Human t-Pa)

- Reteplase (Mutant form of human t-Pa, more fibrin specific)

- Tenecteplase (Mutant form of human t-Pa with a longer half life)

2. Other thrombolytic agents

a. Acylated plasminogen: streptokinase activator complex (Anistreplase) (Discontinued in USA)

b. Single chain pro urokinase (Pro-UK, SCU-PA) (Under development)

c. Plasmin (Under development)

C. Practical Aspects of Thrombolytic Therapy

Effects of various thrombolytic agents can be depicted in the following figure. Fibrinolytic processes can occur in blood (plasmatic) and on the thrombus.

In Blood In Thrombus Plasma Fibrin-Bound Plasminogen Plasminogen

T-PA scu-PA APSAC UK SK

Plasmin Plasmin

Antiplasmin

Fibrinogen degradation (“Lytic State”) Fibrin degradation (Thrombolysis)

6 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

1. Development of the plasma fibrinolytic state: Several biological changes occur after the administration of thrombolytic agents. Some of these are listed below:

a. Circulating plasminogen activator

b. Plasminogen converted to plasmin

c. Antiplasmin complexes with and inhibits plasmin

d. Free plasmin

e. Plasmin degradation of fibrinogen

f. Degradation of other plasma clotting factors

g. Hypocoagulable state

2. Major effects of Thrombolytic Therapy:

Besides dissolving the clots, thrombolytic agents produce multiple actions. Some of these can be summarized in the following:

EFFECT EVENT PATHOGENESIS Clinical Benefit Thrombolysis Degradation (solubilization) of fibrin in the thrombus Side-effect Systemic lytic state Degradation of plasma fibrinogen by circulating plasmin Complication Bleeding Degradation of fibrin in hemostatic plugs (possibly also the hypocoagulable state) adversely influenced by prolonged duration of treatment

JF

7 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

Effect of Thrombolytic Therapy on the Fibrinogen and Plasminogen Levels (Note the decrease in fibrinogen after thrombolytic agents).

JF

8 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

3. Clinical Usage of Thrombolytic Agents:

Thrombolytic agents are now routinely used for a variety of thrombotic conditions. Their clinical acceptance is gradually increasing.

a. Acute Myocardial Infarction:

Large numbers of patients with myocardial infarction have a thrombus in the coronary vessels, with the incidence of occlusion being 70% after the onset of pain. Several thrombolytic agents are currently used for the treatment of myocardial infarction.

1. Narrow Lumen (Atherosclerosis)

4. Fibrin formation

2. Platelet burden

3. Tissue Factor release

Acute occlusion of the coronary artery leading to the formation of a fibrin-rich clot, which may lead to myocardial infarction.

A fresh thrombosis in the coronary artery. Platelet aggregates forming of a thrombus resulting in plaque rupture leading to a fresh clot formation and a myocardial infarction.

Time plays a crucial role for the success of thrombolytic therapy. Older clots are less susceptible to the lytic action of thrombolytic agents.

b. Peripheral Arterial Occlusion:

Thrombolytic agents such as urokinase and streptokinase have been routinely used in the dissolution of arterial occlusions. Both intravenous and localized treatments are used.

c. Deep Venous Thrombosis:

Both streptokinase and urokinase were initially used for the treatment of DVT. Both localized and systemic treatment can be used.

d. Pulmonary Embolism: 9 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

Both streptokinase and urokinase were originally used in large multicenter clinical trials in the U.S.A. Both local and systemic infusions of streptokinase and urokinase have been used. t-PA is not used in this indication.

e. Thrombotic stroke. Acute management of thrombolytic and ischemic stroke

f. Catheter Clearance:

For shunts, grafts and extracorporeal circulation, these agents offer very efficient cleansing effects.

D. Clinical Results on the Use of Thrombolytic Agents in Myocardial Infarction:

Thrombolytic agents have been successfully used in various conditions such as DVT, pulmonary embolism, peripheral occlusive disorders and other thrombotic conditions.

E. Complications of Thrombolytic Therapy:

1. Bleeding

2. Re-occlusion

3. Stroke

4. Others

F. Absolute Contraindication of Thrombolytic Therapy:

1. Intracranial bleeding

2. Massive hemorrhage

G. Other Contraindications

H. Drug Interactions with Thrombolytic Agents:

1. Antiplatelet Drugs

2. Heparin

3. Dextrans

10 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

I. Pharmacologic Antagonist for Thrombolytic Agents:

1. EACA (Epsilon-amino caproic acid)

2. Tranexemic Acid (Trans-4-Aminoethylcyclohexane 1-Carboxylic Acid) 3. Aprotonin (Trasylol)

III. DEFIBRINOGENATING ENZYMES

A. General Considerations:

A number of venoms and biologics contain enzymes that can digest fibrinogen. Some of these agents have been found to be useful for therapeutic purposes.

1. Ancrod is tested in stroke

IV. CORONARY ANGIOPLASTY AND STENTS

A. Anticoagulants during coronary angioplasty.

B. Stents

1. Bare metal stents

2. Drug eluting stents

3. Disposable stents

11 Pharmacology & Therapeutics Pharmacology of Thrombolytic Agents November 2, 2012 J. Fareed, Ph. D

Thrombolytic Agents Important Points to Remember

DRUG MECHANISM OF ROUTE OF INDICATIONS SIDE ACTION ADMINISTRATION EFFECTS

Streptokinase Fibrinolytic Intravenous Thrombolysis, stroke, MI, Bleeding PE Urokinase Fibrinolytic Intravenous Thrombolysis, stroke, MI, Bleeding PE Tissue plasminogen Fibrinolytic Intravenous Thrombolysis, stroke, MI Bleeding activator Epsilon amino caproic Anti-fibrinolytic Intravenous Reversal of bleeding Hypotension acid (AMICAR)

Aprotonin (Trasylol) Anti-fibrinolytic Intravenous Reversal of bleeding Graft thrombosis

Ancrod Fibrinolytic Intravenous Stroke Allergic reaction

Tranexamic acid Anti-fibrinolytic Intravenous Reversal of bleeding Retinopathy (AMCHA)

12