Brief history

Erlich: formulate the hypothesis of selective toxicity for

drugs against bacteria

1909 - Salvarsane for syphilis treatment (arsenic compound)

1928- Fleming descovered penicillin

1939 - Florey and Chain industrial production of

penicillin

The photo (courtesy of Merck & Co., Inc.) shows how the
growth of bacteria on the agar in a culture dish has been
inhibited by the three circular colonies of the fungus
Penicillium notatum. The antibiotic penicillin, diffusing
outward from the colonies, is responsible for this effect. Today,
penicillin is made from cultures of Penicillium chrysogenum
that has been specially adapted for high yields.

CLASSIFICATION
A. Antibacterial agents that inhibit the cell wall synthesis
B. Antibacterial agents that alter the function of the cytoplasmic
membrane
C. Antibacterial agents that inhibit the protein synthesis

D. Antibacterials that inhibit the nucleic acid synthesis

Antibacterial agents that inhibit the cell wall

synthesis
o Beta-lactam antibacterial agents
o Glycopeptides
o Phosphomycine
o Cicloserine
o Bacitracine

Beta-lactam antibacterial agents

o Penicillins
o Cephalosporines

o Carbapenemes
o Monobactam

Penicillins
o penicillins are compounds produced and released by fungi
from genus Penicillium.
o Chemistry:all penicillins are derived from 6aminopenicillanic acid.
o The antibacterial and pharmacolo-gical properties of
different penici-llins depend on the side chain attached to
the nucleus.

: Penicillin - Mechanism of action **

o The bacterial targets of penicillins are known as penicillin
binding proteins (PBP) that are enzymes: transpeptidase,
carboxypeptidase, autolytic enzymes.
o The inactivation of transpeptidases and the activation of
autolysins result in the rapid destruction of peptidoglycan
and dissolution of the cell wall, which leads to bacterial
lysis (-cid effect).

Penicillin and bacterial resistance

Some bacteria produce enzymes that inactivate beta-lactams,
known as beta-lactamases.

Penicillins classification:
1- Natural
2- Semi-synthetic penicillins

Antibacterial spectrum
o Natural penicillins are narrow spectrum antibiotics that are
primarily active against gram-positive bacteria
(enterococci are only inhibited), gram-negative cocci,
Treponema pallidum and most anaerobes (except Bacteroides fragilis).
o Penicilinase resistant penicillins (group M
penicillins): methicillin, oxacillin, nafcillin, cloxacillin,
dicloxacillin.
o Penicilinase resistant penicillins are preferred for the
treatment of Staphylo-coccus aureus infections, which have
a high frequency of beta-lactamase positive isolates.
o Otherwise, these penicillins have the same spectrum of
bacterial susceptibility as the natural penicillins.

Extended spectrum penicillins

This group includes:
1. aminopenicillins (ampicillin, amoxicillin);
2. carboxypenicillins (carbenicillin, ticarcillin);
3. ureidopenicillins (azlocillin, mezlocillin, piperacillin);
4 .amidinopenicillins (mecilinam).
o They are effective against a great variety of gram-positive and
gram-negative bacteria.
o Some of these broad-spectrum penicillins, such as carbenicillin,
piperacillin, are active against Pseudomonas.
o Broad-spectrum penicillins are penicillinase susceptible.
o The concomitant use of beta-lactamase inhibitors (clavulanic
acid, sulbactam, tazobactam) can reduce this susceptibility.

Beta-lactamase inhibitors
o They dont have important antibac-terial effect, but
they block the beta-lactamase activity, excepting
chromo-somal cephalosporinases.
o E.g., clavulanic acid, sulbactam, tazobactam.
o Associations:

o amoxicillin + clavulanic acid;

o ticarcillin + clavulanic acid;
o ampicillin + sulbactam.

Toxicity
o Because the bacterial target of penicillins are enzymes
unique to bacteria, generally, the penicillins have very
limited toxicity.
o The most severe side effects are allergic reactions,
which depend on individual predisposition.

Cephalosporines classification

The cephalosporines are classified into 5 generations, roughly

parallel to their chronological development.

First generation cephalosporines. E.g., cephazolin, cephalotin

(injectable), cephalexin (oral).

Second generation cephalosporines. E.g., cephamandole,

cephuroxime, cefoxitine (injectable), cefaclor (oral).

Cephalosporines antibacterial spectrum

o Only some 2nd-generation cephalosporines are active against
anaerobes (e.g., cefoxitine, cefote-tane).
o Some 3rd and 4th generation cephalosporines are active on P.
aeruginosa (e.g., ceftazidime, cefoperazone, cefepime,
cefpirome).
o 5th gen: active as 4th generation, and on S. aureus resistant to
methillin (MRSA) and other Gram positive bacteria, large broad
spectrum on Gram negative (not active in non-fermenter as
Pseudo-monas).

Cephalosporines toxicity
o Because the structures of cephalos-porines and penicillins are
similar, 10-15% of the patients allergic to penici-llin may be
allergic to cephalosporines, too.

o Cephalosporines are more toxic than penicillins; the most toxic

are the first generation cephalosporines.

Other beta-lactam antibacterial agents

o Carbapenems (Imipenem, Meropenem).
o These agents have a very broad antibacte-rial spectrum (grampositive and negative, aerobic and anaerobic organisms).
o They are resistant to beta-lactamases.
o They are not active on methicillin-resistant staphylococci.
o Monobactams (Aztreonam) are effective against a narrow
spectrum of aerobic gram-negative bacteria, including
Pseudomonas.
o They are resistant to beta-lactamases.

Glicopeptides (vancomycin, teichoplanin);

o They must be given parenterally in the treatment of systemic
infections because it is poorly absorbed by the intestinal mucosa.
o They realize active concentrations in CSF. Vancomycin can be
given orally for the local treatment of intestinal infections (e.g.,
pseudomembranous colitis produced by Clostridium difficile).
o Toxicity. Vancomycin is more toxic than penicillins, especially for
kidneys

Bacitracin
o Inhibits peptidoglycan synthesis by interfering with the recycling
of the phosphorilated lipid carrier.
o It is active against gram-positive bacteria.
o Bacitracin is nephrotoxic and ototoxic when given parenterally;
therefore it is mainly used in topical ointments (only local).

Vancomycin and beta- lactams like penicllin interfere with

cell wall synthesis (1)

Antibacterial agents that alter the function of

the cytoplasmic
membrane

o Polymyxines are
polypeptides with
big molecular
weight.
o E.g., polymixine B,
polymixine E
(colistine).
o Mechanism of
action
o They modify the structure of the cytoplasmic
membrane, which disturb the active transport of
some molecules through it.
o They are bactericidal
o Antibacterial spectrum
o Gram-negative bacilli and cocobacilli (aerobic or
facultative anaerobic).

Antibacterial agents that inhibit the protein

synthesis:
1. Aminoglycosides
2. Tetracyclines
3. Chloramphenicol
4. Macrolides lincosamides streptogramines (MLS)

Aminoglycosides
o Natural aminoglycosides:
produced by Streptomyces: streptomycin,
neomycin, kanamycin, tobramycin,
spectinomycin;
produced by Micromonospora: gentamycin,
sisomycin.

o Semisynthesis aminoglycosides:
o kanamycin derived: amikacin;

o sisomycin derived: netilmycin.

o Mechanism of action Aminoglycosides bind the 30S
ribosomal subunit, which disturbs the protein synthesis and
produce non-functional proteins.

Aminoglycosides - Antibacterial spectrum:

o Aminoglycosides are bactericidal.
o They are active on facultative anaerobic gram-negative bacilli
and on staphylococci. Gentamycin, tobramycin, amikacin and
netilmycin are also active on Pseudomonas aeruginosa.
o Streptomycin is particularly active on mycobacteria, Yersinia
pestis and Brucella.
o Administration:aminoglycosides are not absorbed from the

digestive tract; thus, they are given parenterally. They may be

given locally in meningitis.
o Toxicity: ototoxic, nephrotoxic, except spectinomycin.
o Gentamycin, tobramycin, amikacin, netilmycin have lower
toxicity levels.
o Aminoglycosides realize concentrations very close to the toxic
ones (their serum concentrations have to be checked).
o Natural tetracyclines: chlortetracycline, oxytetracycline.
o Semisynthesis tetracyclines: tetracycline, doxycycline,
minocycline

Tetracyclines - Mechanism of action

o Tetracyclines are bacteriostatic.

o They fix on the 30S ribosomal subunit, blocking the binding of

tRNA on the complex mRNA-ribosom; thus, they stop peptide
elongation.

How antibiotics work ?

o For example vancomycin and b- lactams like penicllin interfere
with cell wall synthesis (1).
o Erythromycin and tetracyclin disrupt protein synthesis at
the

ribosome (2).
o Quinolones inhibit enzymes involved in DNA synthesis (3) and
sulfonamides also interfere with DNA synthesis by mimicking
naturally-occurring building materials.

Tetracyclines - Antibacterial spectrum

o Tetracyclines are broad-spectrum antibacterials, active on grampositive and gram-negative, aerobic and anaerobic organisms.
o They are also active on: spirochete, mycoplasmas, chlamydia,
rickettsia.
o They are not active on Pseudomonas aeruginosa.

Tetracyclines - Administration.
o When given orally, they are well absorbed. They dont realize
active concentrations in CSF.
o They are not eliminated by urine, so, they are not effective in
urinary tract infections.
o Doxycycline, minocycline are long acting tetracyclines and
require less frequent administration.

Tetracyclines - Side effects

o They produce brownish staining of the teeth and they affect the
growth of long bones in children.
o Thats why they are counter-indicated in children less than 8
years old and in pregnant women.
o Tetracycline administration encourages candidiasis as a result of
the loss of the normal flora.

Chloramphenicol
o Chloramphenicol is the first antimicrobial compound synthesized
in the laboratory.
o Tiamphenicol is a less toxic derivative.
o Mechanism of action: it blocks protein synthesis by fixing on
the 50S ribosomal subunit and inhibiting the
peptidiltransferase.

Chloramphenicol - Antibacterial spectrum.

o Chloramphenicol is bacteriostatic against most bacteria, but it is
bactericidal against Haemophilus influenzae, Neisseria
meningitidis, Streptococcus pneumoniae.

Chloramphenicol Administration
o Chloramphenicol can be given orally or in injections, realizing
good concentrations in tissues, even in CSF.
o It is conjugated in the liver, the resulted inactive compound being
eliminated by urine.

Chloramphenicol - Toxicity.
o In newborn or premature, chloramphenicol produces gray
baby syndrome because the liver is incapable to conjugate the
compound.
o In adults, there is a dose-dependent toxic effect on the bone
marrow, which is reversible.

o In a very low number of patients (1: 25000), a dose

independent toxic effect may appear the irreversible, lethal
bone marrow aplasia.

Macrolides:
o Erythromycin
o Roxitromycin
o Clarithromycin
o Azithromycin
o Spiramycin
o Josamycin
Mechanism of action. Macrolides bind to the 50S
ribosomal subunit, immobilize peptidyl tRNA and cause
premature peptide chain termination.
Antibacterial spectrum: erythromycin is active against
gram-positive cocci and bacilli, including anaerobes,
Legionella pneumophila, Bordetella pertussis, Campylobacter
jejuni, mycoplasmas, chlamydia.
Erythromycin is the alternative to penicillin in the treatment of
group A streptococcal infections.

The new macrolides (clarithromycin, azithromycin) are also

active on gram-negative bacteria: Moraxella catarrhalis,
Haemophilus influenzae.
Clarythromycin is active in the treatment of Helicobacter
pylori gastritis and in infections with Mycobacterium aviumintracellulare.
Administration: macrolides are given orally and realize good
concentrations in tissues, but not in CSF. They are eliminated
predominantly by bile.
Toxicity: macrolides have low toxicity. They may cause
gastric intolerance.

Lincosamides:
Ex: Lincomycin
Clindamycin
Antibacterial spectrum: lincosamides are active against
staphylococci, gram-positive and gram-negative anaerobes,
including Bacteroides fragilis.
Adverse effects: lincosamides encourage, more than other
antibacterials, the pseudomembranous colitis with Clostridium
difficile.

Antibacterials that inhibit the nucleic acid synthesis

1. Sulfonamides
- Sulfizoxazole
- Sulfamethoxazole etc.
- Mechanism of action. Sulfonamides are bacteriostatic. They
inhibit the folic acid synthesis by inhibiting dihidropteroate
synthetase.
Antibacterial spectrum. Sulfonamides are active on:
Gram-positive and gram-negative bacteria, except Pseudomonas
aeruginosa;
Actinomyces israelii, but not other anaerobes;
Chlamydia.

Administration: orally, resulting in good concentrations in tissues.

Elimination by urine.
Adverse effects:
hypersensitivity reactions, especially after local administration;
acute hemolytic anemia in patients with G6PD deficiency;
increased concentrations of non-conjugated bilirubine in newborn.

Trimethoprim:
o Mechanism of action. Bacteriostatic. It inhibits folic acid
synthesis by blocking dihidrofolate reductase.
o Antibacterial spectrum. Similar to sulfonamides.
o Adverse effects. It may produce skin rash or bone marrow
depression.

Cotrimoxazol:
o Trimethoprim + sulfamethoxazole (5/1) =
cotrimoxazol, a synergistic combination. Each
component is bacteriostatic, but the combination is
bactericidal.
o It is particularly useful in the treatment of genitourinary
tract infections, bacterial gastro-enteritis and it is
frequently used in the long-term prophylaxis of bacterial
infections in immune-compromised hosts.

Quinolones: bactericidal effect

First generation:
- Nalidixic acid
- Pipemidic acid etc.
Spectrum: active only on Enterobacteriaceae.
Second generation (Fluoroquinolones):
Norfloxacin

- Pefloxacin
- Ofloxacin
- Ciprofloxacin
- Sparfloxacin, etc
Activity spectrum: fluoroquinolones have
extended spectrum, being active on
- GN bacilli, including Ps. aeruginosa,
- GN cocci and cocobacilli,
- some GP (staphylococci, beta haemolytic
streptococci),
- Legionella pneumophila,
- chlamydia and
- mycoplasmas.
3rd generation
-

levofloxacine, gatifloxacine,
moxifloxacine;

activity spectrum: as 2nd, plus on S. pneumoniae, and more efficient for: Mycoplasma and
Chlamydia.

4th generation
-

trovafloxacine,
gatifloxacine,moxifloxacine,

- activity spectrum: as 3rd, plus, active on

anaerobic bacteria.
Under evaluation: delafloxacine, nemonoxacine

Quinolones:

Administration.
Nalidixic acid is given orally, but it realizes active
concentrations only in the kidneys.
Fluoroquinolones are systemic quinolones, which, after oral
administration, realize active concentrations in tissues and
CSF, having good penetration in the cells.
They are eliminated predominantly urinary.
Adverse effects.
Fluoroquinolones determine photosensitivity after exposure
to the sunlight.
They have limited applications in children.

Rifampin:
o Mechanism of action. Bactericidal;
o it inhibits RNA polymerase DNA dependent.
o Antibacterial spectrum. Mycobacteria, gram-positive
cocci (staphylococci), gram-negative cocci and coccobacilli,
Legionella pneu-mophila, chlamydia, rickettsia.

Administration.
After oral administration, it realizes active
concentrations in tissues, including CNS.
It concentrates in phagocytes and has billiary and
urinary elimination.

Adverse effects. Hepatic disorders.

o Mechanism of action. After penetration in the bacterial
cell, intermediate meta-bolism compounds interact with
DNA.
o Antibacterial spectrum. Protozoa, anaerobic and
microaerophilic bacteria.
o Administration. After oral adminis-tration, it realizes
active concentrations in tissues and CSF. Urinary
elimination.

o Adverse effects. They are, generally, well tolerated.

Antimycobacterial agents
o Conditions for an effective antimycobacterial therapy:
o the antimycobacterial agents have to be active against
extra- and intra-cellular bacilli, including the dormant
ones;
o to prevent relapses by a long-term therapy;
o To prevent the resistance phenomenon by using at least
three associated therapeutical agents.
o The antimycobacterial agents are classified:
o First line therapy important antimycobacterial effect and low toxicity
o Second line therapy more toxic and less
efficient

First line:

Isoniazid

Mechanism of action. Bactericidal by

inhibition of the mycolic acids synthesis. It is effective against
extra- and intra-cellular bacilli.
o Administration. Orally given, it realizes active tissue
concentrations. Urinary elimination.
o Adverse effects. Hepatotoxicity, neurotoxicity (especially
in elderly patients, diabetics, alcoholics).

Rifamycins - Rifampicin, Rifabutin and

Rifapentine

Rifampin and ansamycine

o Bactericidal; active on extra- and intra-cellular

mycobacteria and bacilli with slow multiplication.

First line:
Ethambutol
o Bacteriostatic by inhibiting the transfer of mycolic acids
from the cytoplasm to the cell wall. Active only on extracellular bacilli.
o Oral administration; it realizes good concentrations in
tissues and CSF; renal elimination.
o Adverse reactions: periferic neuropathy.
o Streptomycin
o Bactericidal on extra-cellular bacilli.

Second line antibiotics used

o Cycloserine
Broad spectrum antibiotic
This blocks the synthesis of peptidoglycan by inhibiting Dalanine racemase and D alanine ligase.
o Fluoroquinolones
Broad spectrum antibiotics
Interact with DNA gyrase and DNA topisomerase which
means that super-coiling and replication are altered.
o Capreomycin and viomycin
Viomycin inhibits cell free translation systems
Capreomycin may inhibit protein synthesis
o P-aminosalicylic acid
Discovered 1946 but now rarely used
Possibly competes with p-aminobenzoic acid or with
salicylate dependent biosynthesis of iron chelating
mycobactins
o Thiacetazone
A thiosemicarbazone with unknown action but may
involved in inhibiting mycolic acid synthesis

o Ethionamide
Produced from 1966

o Kanamycin or amikacin
Affect ribosomal proteins
Produced from 1957
o Ofloxacin
Produced from 1987 onwards
A drug that interacts with DNA gyrase
o Quinolones
Affect DNA gyrase and also DNA replication
o Acridinones
May involve inhibition of RNA synthesis
o Oxazolidinones
Inhibit bacterial protein synthesis
o Gangamycin
Synthetic antibiotic
Inhibit cell wall synthesis

Principles and Definitions

Clinical resistance to an antimicrobial agent occurs when the
MIC of the drug for a particular strain of bacteria exceeds that
which is capable of being achieved with safety in vivo.
1. Resistance that appears after introduction of an antimicrobial
agent into the environment usually results from a selective
process, i.e. the agent selects for survival of those strains
possessing a resistance gene.

Resistance can develop in a single step or it can result from

the accumulation of multiple mutations.
2. Cross resistance implies that a single mechanism confers
resistance to multiple antimicrobial agents while multiple
resistance implies that multiple mechanisms are involved.
Cross resistance is commonly seen with closely related
antimicrobial agents while multiple resistance is seen with
unrelated antimicrobial agents.

Mechanisms of natural bacterial

resistance:
Low permeability of the cell wall.
E.g., resistance of mycobacteria to the antibacterial
agents active on non-acid fast bacteria;
natural resistance of gram-negative bacteria to glicopeptides
Absence of the antibiotics target.
- E.g., resistance of mycoplasmas to the cell wall synthesis
inhibitors.
Enzymatic inactivation of antibiotics by constitutive
enzymes.
- E.g., natural resistance of Yersinia enterocolitica to
aminopenicillins.

Modification of the cell wall permeability:

E.g., resistance of Pseudomonas aeruginosa
to carbapenems;
resistance of Mycobacterium tuberculosis to isoniazid,
ethiona-mide, cycloserine, PAS.

Modification of the target:

o biochemical modification of the PBP (penicillin binding
proteins), which diminishes the enzymes affinity for that

antibiotic. E.g., resistance of pneumococci to penicillin,

resistance of staphylococci to methicillin;
o resistance to trimetoprim and sulfonamides;
o resistance to rifampicine by modification of the RNA
polymerase affinity;
o resistance to quinolones by modification of their affinity to
DNA girases

Enzymatic inactivation of antibiotics:

o Aminoglycosides acetyl-transferases; adenil-transferases,
phosphorilases;
o Chloramphenicol chloramphenicol-acetyl-transferase;
o Beta-lactams beta-lactamases;
o Chromosomal cephalosporinases they are not inactivate by
beta-lactamase inhibitors.
o Beta-lactamases inactivated by inhibitors: sulbactam,
clavulanic acid, tazobactam.
o E.g., staphylococcal penicilinase.
o R plasmids have one or several resistance determinants that can
spread epidemically by conjugation or transduction, among the
same species or among species. Several resistance determinants
are transposable elements.

ANTIBIOTIC ASSOCIATIONS
o Indications:

o severe infections, before the identification of the etiological

agent;
o in joint infections;
o to obtain a synergistic effect, to surpass bacterial
resistance in severe infections or to reduce the dose of a
toxic antibiotic;

o to prevent selection of resistant mutants in the treatment

of severe infections (e.g., tuberculosis).

An antibiotic association can be:

synergistic: the activity of the association is bigger than the
sum of the individual activity of the antibiotics:
antagonistic: the activity of the association is smaller than the
activity of each separated antibiotic;
additive: the activity of the association is equal to the sum of
the activities of the two antibiotics;
indifferent: the association has a smaller activity than the most
efficient antibiotic of the association.

Rules for the association of the antibiotics

o

It is avoided the association of 2 toxic antibiotics:

aminoglycosides or with polymixines (the toxic effects are
summed).

It is avoided the association of a bacterios-tatic by inhibition of

the protein synthesis (tetracyclines, macrolides) with a bactericidal antibiotic (penicillins, aminoglyco-sides) (antagonistic
effect).

It is indicated the association of antibiotics that block successive

steps of a metabolic pathway (e.g., trimetoprim + sulfamethoxazole).

It is indicated the association of an antibiotic with another one

that encourages its penetration in the bacterium (e.g., penicillin
+ aminogly-cosides against enterococci).

It is indicated the association in which one antibiotic is protected

from enzymatic effects by the other one (e.g., ampicillin +
sulbactam).