Presented By Madeeha Naz

Antimicrobial drugs

Antimicrobial drugs are chemicals used to prevent
and treat microbial infections.

Antimicrobial drugs can be classified as
antibacterial, antifungal, antiviral, or
antiparasitic depending on the type of microbe the
drug targets.

Origin & Classification of Antimicrobial
Drugs
The development of antimicrobial drugs began in the late 1800's
with Paul Erlich, a German scientist, who discovered that arsenic
compounds were an effective treatment for syphilis. Unfortunately,
these compounds were also highly toxic to the patients they were
being used to treat.
In 1928 Sir Alexander Fleming accidentally stumbled upon the
discovery of the wonder drug, penicillin. As he was inspecting a
plate of Staphylococcus aureus contaminated with the mold
Penicillium, Fleming noticed that the mold had inhibited the
growth of the bacterial colonies. He later isolated the compound
responsible for this inhibition and named it penicillin.
Classification of Antimicrobial
drugs

based upon how they are made.
based upon their spectrum or range of effectiveness.
based upon their primary site of action.
Classification based upon how they are
made.

Antimicrobial drugs can be naturally-derived,
semi-synthetic or synthetic.

Naturally-derived antibiotics.
Penicillin, derived from the fungus Penicillium.
Cephalosporin comes from the fungus
Cephalosporium.
Bacitracin and polymyxin which are produced by
the soil bacteria, Bacillus licheniformis and
Bacillus polymyxa

Semi-synthetic drugs

Isolated from natural sources, but then chemically
modified in a laboratory to make the drugs more
effective, longer lasting, easier to administer,
and less toxic to the patient.

For example,ampicillin and methicillin are
semi-synthetic drugs derived from penicillin.

Synthetic drugs

compounds that are completely artificial and are
synthesized in a laboratory. Synthetic drugs tend to
have high toxicity to both the microbe and the human
host.
Classification based upon their spectrum
Broad-spectrum drugs are effective against many
types of microbes and tend to have higher toxicity to
the host.(Tetracycline)

Narrow-spectrum drugs are effective against a
limited group of microbes and exhibit lower toxicity to
the host. (Penicillin)
Classification based upon their primary
mode of action.
Antibacterial drugs regulate microbial growth and
division by:
1) inhibiting cell wall synthesis;
2) disrupting the plasma membrane;
3) blocking protein synthesis;
4) disrupting metabolic pathways;
5) inhibiting nucleic acid (DNA and RNA)
synthesis.
Cell wall inhibitors
block the synthesis and repair of the bacterial cell wall
and include drugs such as penicillin, cephalosporin,
vancomycin, bacitracin.

Plasma membrane inhibitors
a drug that disrupts the bacterial plasma such as
Polymyxin.


Protein synthesis inhibitors

include those that target the 50S ribosomal subunit
(chloramphenicol, erythromycin, and
clindamycin)
and those that target the 30 ribosomal subunit
(aminoglycosides, tetracyclines, and
streptomycin).

Nucleic acid inhibitors
block replication and transcription and include drugs
such as ciprofloxacin (DNA) and rifampin (RNA).

Metabolic inhibitors
prevent folic acid synthesis and include sulfa drugs
and trimethoprim.

Drug Resistance
Microbes develop drug resistance due to genetic
mutations and by acquiring genes from other
microbes via processes like conjugation,
transformation, and transduction.

Humans contribute to the development and spread of
drug resistance by:
1) not using the appropriate drug for a particular type
of infection;
2) not finishing medication or not taking it properly;
3) using antimicrobial drugs when they are not
needed.
When an antimicrobial drug is present and the
majority of drug-sensitive cells die, the drug-resistant
cells left behind will be allowed to grow unchecked
until they outnumber the drug-sensitive cells.

Why is antimicrobial resistance a
global concern
fail to respond to the standard treatment, resulting in
prolonged illness and greater risk of death.
patients remain infectious for a longer time, increasing
the risk of spreading resistant microorganisms to
others.
becoming untreatable and uncontrollable
resistant to first-line medicines, more expensive
therapies must be used.
increases health-care costs and the economic burden
to families and societies.
Some types of bacteria have developed multiple-drug
resistant forms.
For example, Staphylococcus aureus has developed
resistance to penicillin, methicillin(MRSA: Methicillin-
resistant Staphylococcus aureus),
and vancomycin (VRSA: Vancomycin-resistant
Staphylococcus aureus).
Definitions
Minimum inhibitory concentration(MIC)
Lowest concentration of an antimicrobial agent that visibly
inhibits the growth of the organism.

Minimum bactericidal concentration (MBC)
Lowest concentration of the antimicrobial agent that results
in the death of the organism.
Definitions
Susceptible S
Interpretive category that indicates an organism is inhibited
by the recommended dose, at the infection site, of an
antimicrobial agent
Intermediate I
Interpretive category that represents an organism that may
require a higher dose of antibiotic for a longer period of
time to be inhibited
Resistant R
Interpretive category that indicates an organism is not
inhibited by the recommended dose, at the infection site,
of an antimicrobial agent.
Reasons and Indications for
Antimicrobial Susceptibility Testing
(AST)
Goal
Offer guidance to physician in selecting effective
antibacterial therapy for a pathogen in a specific body site
Performed on bacteria isolated from clinical
specimens if the bacterias susceptibility to particular
antimicrobial agents is uncertain
Factors to Consider When Testing is
Warranted
Body site of infection

Susceptibility not performed on bacteria isolated from body
site where they are normal flora
Ex. Susceptibility for E. coli is NOT performed when isolated
from stool, but IS performed when isolated from blood
Factors to Consider When Testing is
Warranted
Presence of other bacteria and quality of specimen
Ex. Two or more organisms grown in a urine specimen
Host status
Immunocompromised patients
Allergies to usual antimicrobials
Selecting Antimicrobial Agents for
Testing and Reporting
Clinical & Laboratory Standards Institute (CLSI)
Develop standards, methods, QC parameters, and
interpretive criteria for sensitivity testing
If necessary, can alter the breakpoints of the SIR (
susceptible, intermediate, resistant) based on emerging
resistance

Selecting Antimicrobial Agents for
Testing and Reporting

There are approximately 50 antibacterial agents
Follow CLSI recommendations
Each laboratory should have a battery of antibiotics
ordinarily used for testing
Drug formulary decided by medical staff, pharmacists,
and medical technologists
Selection of Antimicrobial Agents
Generally, labs choose 10-15 antibiotics to test
susceptibility for GP organisms and another 10-15 for
GN organisms
Too many choices can confuse physicians and be too
expensive
Primary objective
Use the least toxic, most cost-effective, and most clinically
appropriate agents
Cheap in cost, broader-spectrum agents

Ideal antimicrobial agent
An ideal antimicrobial medication should be:
1) highly toxic to the microbe;
2) non-toxic to the host;
3) not interfere with the ability of the host to fight
other diseases; and
4) not lead to the development of drug resistance.
Methods of Performing AST
Agar dilution method
Broth macrodilution / Tube dilution
Broth microdilution
Disk diffusion method
Gradient diffusion method (E-Test)
Standardization of Antimicrobial
Susceptibility Testing
Inoculum Preparation
Use 4-5 colonies NOT
just 1 colony
Inoculum Standardization
using 0.5 McFarland
standard
Methods of Performing AST
Agar Dilution
Dilutions of antimicrobial agent added to agar
Growth on agar indicates MIC
Broth macrodilution/Tube Dilution Tests
Two-fold serial dilution series, each with 1-2 mL of antimicrobial
Too expensive and time consuming
Microdilution Tests
plastic trays with dilutions of antimicrobials
Disk Diffusion/ Kirby- Bauer
Procedure
Use a well-isolated, 18-24 hour old
organism
Transfer organism to a broth
Either tryptic soy/sterile saline
Ensure a turbidity of 0.5 McFarland
Inoculate MH agar by swabbing in
three different directions Lawn of
growth
Place filter paper disks impregnated
with anitmicrobial agents on the agar
Invert and incubate for 16-18 hours at
35-37
o
C in non-CO
2
Disk Diffusion/ Kirby-Bauer
During incubation, drug
diffuses into agar
Depending on the organism
and drug, areas of no
growth form a zone of
inhibition
Zones are measured to
determine whether the
organism is susceptible,
intermediate, or resistant to
the drug.
E- test/ Gradient Diffusion Method
MIC on a stick
Plastic strips impregnated
with antimicrobial on one
side
MIC scale on the other
side
Read MIC where zone of
inhibition intersects E strip
scale
Automated
Antimicrobial Susceptibility Test Methods

Detect growth in microvolumes of broth with various
dilutions of antimicrobials
Detection via photometric, turbidimetric, or fluorometric
methods
Types
BD Phoenix
Microscan Walkaway
TREK Sensititre
Vitek 1 and 2


Automated
Antimicrobial Susceptibility Test Methods

Advantages
Increased reproducibility
Decreased labor costs
Rapid results
Software
Detects multi-drug resistances
ESBLs
Correlates bacterial ID with sensitivity
Disadvantages
Cost
Quality Control in
Susceptibility Testing
Reflects types of patient isolates & range of susceptibility
Frequency of quality control depends on method, CLSI, or
manufacturer
Reference strains of QC material
American Type Culture Collection(ATCC)
E. coli ATCC* 25922
S. aureus ATCC* 25923

The Superbugs
Organisms resistant to previously effective drugs
MRSA
methicillin-resistant Staphylococcus aureus
mecA gene codes for a PBP that does not bind beta-lactam
antibiotics
Resistant to oxacillin
Vancomycin
VRE Enterococcus species
VISA/VRSA- Staphylococcus aureus


The Superbugs: The Beta-Lactamases
Gram negative rods that have genes on chromosomes that code for
enzymes against certain antimicrobials
ESBLs-extended spectrum beta lactamase
Resistant to extended spectrum cephalosporins, penicillins, aztreonam
Examples: E. coli, Klebsiella
Carbapenemases (CRE)
Klebsiella pneumoniae
Resistant to penicillins, cephalosporins, carbapenems, and aztreonam
Cephalosporinases
AmpC enzyme
inducible
SPACE organisms
Controlling the Superbugs
Labs Role

Recognize and report isolates recovered from clinical
specimens

Methods for identification include automated systems and
screening agars


Controlling the Superbugs
Role of Health Care Workers/Facilities
Hand hygiene with the use of alcohol-based hand rubs or soap
and water after patient care/ performing lab procedure.
Contact precautions for patients identified as colonized or
infected with a superbug.
Healthcare personnel education about the methods of
transmission, contact precautions, and proper use of hand
hygiene
Minimization of invasive devices (catheters, etc.)
Proper administration of antimicrobial agents where therapy is
selected for susceptible organisms for the proper duration.

References
http://www.biomerieux-diagnostics.com/servlet/srt/bio/clinical-
diagnostics/dynPage?doc=CNL_CLN_PRD_G_PRD_CLN_22
http://www.cdc.gov/std/gonorrhea/lab/diskdiff.htm
http://www.who.int/drugresistance/Antimicrobial_Detection/en/index.ht
ml
Kiser, K. M., Payne, W. C., & Taff, T. A. (2011). Clinical Laboratory
Microbiology: A Practical Approach . Upper Saddle River, NJ: Pearson
Education.
Mahon, C. R., Lehman, D. C., & Manuselis, G. (2011). Textbook of
Diagnostic Microbiology (4th ed.). Maryland Heights, MO: Saunders.
Murray, P. R. (2013, May). Carbapenem-resistant Enterobacteriaceae: what
has happened, and what is being done. MLO, 45(5), 26-30.