Chapter 12 Antimicrobial Therapy Topics: • Ideal drug - Antimicrobial Therapy - Selective Toxicity • Terminology - Survey of Antimicrobial Drug • Antibiotics - Microbial Drug Resistance - Drug and Host Interaction An ideal antimicrobic: Chemotherapy is the use of any chemical - soluble in body fluids, agent in the treatment of disease. - selectively toxic , - nonallergenic, A chemotherapeutic agent or drug is any - reasonable half life (maintained at a chemical agent used in medical practice. constant therapeutic concentration) An antibiotic agent is usually considered to - unlikely to elicit resistance, be a chemical substance made by a - has a long shelf life, microorganism that can inhibit the growth or - reasonably priced. kill microorganisms. There is no ideal antimicrobic An antimicrobic or antimicrobial agent is Selective Toxicity - Drugs that specifically target a chemical substance similar to an microbial processes, and not the human host’s. antibiotic, but may be synthetic. Antibiotics Spectrum of antibiotics and targets • Naturally occurring antimicrobials – Metabolic products of bacteria and fungi – Reduce competition for nutrients and space • Bacteria – Streptomyces, Bacillus, • Molds – Penicillium, Cephalosporium * * 1 The mechanism of action for different 5 General Mechanisms of Action for antimicrobial drug targets in bacterial cells Antibiotics - Inhibition of Cell Wall Synthesis - Disruption of Cell Membrane Function - Inhibition of Protein Synthesis - Inhibition of Nucleic Acid Synthesis - Anti-metabolic activity Antibiotics weaken the cell wall, and cause the cell to lyse . Cell wall synthesis • Bactericidal • Vancomycin – hinders peptidoglycan elongation • Penicillin and cephalosporins – binds and blocks peptidases involved in cross-linking the glycan molecules Fig. 12.2 The consequences of exposing a growing cell to antibiotics that prevent cell wall synthesis. Affect cell wall synthesis The mechanism of cell wall inhibition by penicillins and cephalosporins Penicillin – Figure 13.11 Penicillin G - drug of choice for streptococci, meningococci, pneumococci, spirochetes, clostridia, aerobic gram-positive rods treponemes - administered parenterally - other than by mouth - why? Penicillin V, ampicillin or other analogues may be used for oral administration Cephalosporins - similar to penicillins 2 Penicillin Penicillin continued • Penicillin chrysogenum • Resistance – if bacteria contain st nd rd • A diverse group (1 , 2 , 3 generations) penicillinases - βββ-lactamase – Natural (penicillin G and V) • Inhibits cell wall synthesis – Semisynthetic (ampicillin, amoxicillin) • Effective against Gram+ bacteria • Structure –Beta-lactam ring – Variable side chain (R group) Effect of β-lactamase on penicillin Penicillins Cephalosporin - beta lactam Cephalosporin continued… • Cephalosporium acremonium (mold) • Resistant to most pencillinases • Widely administered today • Broad-spectrum – inhibits cell wall – Diverse group (natural and semisynthetic- synthesis 4th generation!) rd • Structure • 3 generation drugs used to treat – similar to penicillin except enteric bacteria, respiratory, skin, urinary and nervous system infections • Main ring is different • Two sites for R groups 3 Nucleic acid synthesis • Chloroquine – binds and cross-links the double helix • Other quinolones – inhibits DNA unwinding enzymes (gyrase) and block replication. Ciprofloxacin is an example • Viruses – Analogs of purines and pyrimidines - sometimes considered antimetabolites Rifampin - blocks transcription - can “Red Man Syndrome” cause red man syndrome - a result of accumulation of metabolic products of the antimicrobic in secretions Examples of different antibiotics and their Mostly sites of inhibition on the prokaryotic ribosome seen with anti-viral agents purine purine pyrimidine pyrimidine analog analog 4 Protein synthesis Aminoglycosides • Aminoglycosides • Streptomyces and Micromonospora – Binds the 30S ribosome • Broad-spectrum – Misreads mRNA • Commonly used to treat bubonic • Tetracyclines plague and sexually transmitted – Binds the 30S ribosome diseases – Blocks attachment of tRNA to A site • Chloramphenicol • Inhibits protein synthesis - bind 30S ribosomal subunit – Binds to the 50S ribosome – Prevents peptide bond formation Tetracycline • Streptomyces • Broad spectrum and low cost • Commonly used to treat sexually transmitted diseases • Side effects – gastrointestinal disruption, deposition in hard tissues • Inhibits proteins synthesis - Binds the 30S ribosome and blocks attachment of tRNA Chloramphenicol Erythromycin • Streptomyces • Streptomyces • Broad-spectrum • Structure – macrolide ring • Only made synthetically today • Broad-spectrum • Treat typhoid fever, brain abscesses • Commonly used as prophylactic drug prior to surgery • Side effects – aplastic anemia • Side effects - low toxicity • Inhibits protein synthesis - binds 50S ribosome subunit - prevents peptide • Inhibits protein synthesis - bind to bond formation 50S ribosome subunit- prevents translocation 5 Cell membrane Polyenes • Antifungal • Polymyxins • Commonly used for skin infections – Interact with membrane phospholipids • Targets the membrane - loss of selective – Distorts the cell surface permeability – Leakage of proteins and nitrogen bases • Polyenes – Amp B and Nystatin • Anti-fungal - Polyenes • Amphotericin B - binds to ergosterol found – Amphotericin B and Nystatin- bind to in fungi and protozoa, but not in human sterols on cells membranes. cells - increases membrane permeability • Side effects are numerous due to toxicity of the drug ANTIMETABOLITES Sulfonamides (sulfa drugs) Act either through competitive inhibition or erroneous incorporation – molecular • Synthetic drug mimicry • Based on sulfanilamides • Used in combination with other Sulfonamides - block synthesis of folic synthetics such as trimethoprim acid - and as a result, nucleic acid • Commonly used to treat pneumonia synthesis in AIDS patients Isoniazid - antimetabolite for two • Inhibits folic acid synthesis vitamins The mode of action of sulfa drug Other types of antimicrobials • Antiprotozoan – metronidazole - most are fairly toxic - black hairy tongue – Treat Giardia and amebiasis • Antimalarial – Quinine – malaria • Antihelminthic – mebendazole – Tapeworms, roundworms 6 Antiviral • Limited drugs available Flagyl • Difficult to maintain selective toxicity • Effective drugs – target viral replication cycle – Entry – Nucleic acid synthesis – Assembly/release • Interferon – artificial antiviral drug Antimicrobial Resistance 5 Mechanisms of Resistance 1) Alteration of Targets – usually affects • Resistance factors – R plasmids ribosomes • 5 main mechanisms of 2) Alteration of Membrane Permeability- Change resistance in the receptor that binds the drug • New approaches 3) Development of Enzymes – βββ-lactamase 4) Efflux pumps – Memnbrane proteins many Gram negatives that pump out drug 5) Alteration of Metabolic Pathway – Development of alternate pathway Examples of mechanisms of Demonstration of how natural selection acquired drug resistance enables resistant strains to become dominant βββ-lactamase Membrane permeability Efflux pumps Alter targets Alternate metabolism 7 Human Misuse of Limiting Resistance Antibiotics!!! 1) Constant exposure to high levels of antibiotic 2) Use of multiple antibiotics 3) Restricted use of antibiotics New approaches • Increase drug resistance requires new approaches for developing effective antimicrobials – Prevent iron –scavenging capabilities – Inhibit genetic controls (riboswitches) – Probiotics and prebiotics – Combination therapy – Phage therapy Drug and Host Interaction Main Types of Side Effects Associated with Antimicrobial • Toxicity to organs Treatment • Allergic reactions 1)Toxicity • Suppress/alter microflora 2)Allergy – actual drug or breakdown • Effective drugs products 3)Disruption of Normal Microflora Can Lead to SUPERINFECTIONS!! 8 Disrupting the microflora in the intestine can Development of disease following result in superinfections broad spectrum antimicrobic therapy Pseudomembranous colitis (antibiotic associated diarrhea) - often caused by Clostridium difficile Yeast infection – after broad antibiotic use to treat UTI caused by E. coli Effective drugs An example of the Kirby-Bauer Test • Identify infectious agent • Sensitivity testing • Minimum Inhibitory Concentration (MIC) – visual call The E-test is an alternative to the Kirby-Bauer procedure 9 Multiwell plate to calculate several MICs Antimicrobics have helped us deal with disease, but on the other hand, improper use of antimicrobics have created new difficulties. 10.