Pharmacology: ID & Micro (Fungi & Parasites)

Antifungal Drugs ..................................................................................................................................................................... 2

Chemotherapy of Parasitic Infections ..................................................................................................................................... 5

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 Antifungal Drugs
The big picture:
DRUG INFECTION ROUTE MECHANISM CLASS
Amphotericin B
(deoxycholate)
Deep IV Ergosterol binding
Amphotericin B Polyene
(lipid formulation)
Nystatin Derm/yeast PO/topical/vaginal
Ketoconazole Deep/derm PO/topical
Fluconazole
Deep IV/PO
Itraconazole Ergosterol synthesis Azole
Clotrimazole
Derm/yeast Topical/vaginal
Miconazole
Flucytosine Deep PO DNA/protein synthesis Pyrimidine
Caspofungin
Micafungin Deep IV Cell wall synthesis Echinocandin
Anidulafungin
Gresofulvin Derm PO Microtubule formation Griseofulvin
Terbinafine Derm PO/topical Squalene synthesis Allylamine

General principles: need to be highly specific for fungal target without affecting human counterparts (tough because
both are eukaryotes)

Sterol biosynthesis:
 First part (common to both animals & fungi)
1. Squalene  2,3-oxidosqualene (via squalene 2,3-epoxidase)
2.  lanosterol (via 14-α-demethylase)
3.     zymosterol
 Second part
1. Humans: zymosterol  cholesterol
2. Fungi: zymosterol  ergosterol
 Key point: fungi use ergosterol (more hydrophobic & rigid) instead of cholesterol in their cell membranes

Target: ergosterol in cell membrane (polyenes)

 Note: these act directly on ergosterol (others interfere with biosynthesis)
amphotericin B Mechanism of Action: polyene antifungal agent. Big macrolide ring; half hydrophobic, half hydrophilic, forms a
channel or pore in fungal membranes

Effects: forms cylindrical channel (hydrophobic sides outside, against cell membrane) when bound to sterols &
allows leakage of small molecules resulting in fungal death
Selective Toxicity: Binds more avidly to ergosterol (fungi) than cholesterol; selective toxicity not great

Indications: potentially fatal fungal infections(think of toxicity)

1. invasive aspergillosis,
2. disseminated candidiasis Administration: IV
Toxicity: A lot. NEPHROTOXICITY is dose limiting. Fever, chills, hypotension ("shake 'n bake")
Other: deoxycholate is usual form; also lipid formulations available: same efficacy, less toxicity, 30-40x more $$

Nystatin Very similar to amphotericin, but in topical preparation

Indications: treatment of oral, vulvovaginal, cutaneous candidiasis
Administration: Topical

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 Target: ergosterol biosynthesis
 Note: none of our current drugs target the fungi-specific part of ergosterol biosynthesis!

Azoles (ergosterol biosynthesis)

 imidazole (2 nitrogen atoms) or triazole (3 nitrogen atoms)
Azoles (in general) Mechanism of Action: azole antifungal agent.
 Low doses: inhibits ergestol biosynthesis.
 High doses: may directly damage fungal cell membrane
Effects:
 Low dose: blocks 14-alpha-demethylase, a CYP450 enzyme (lanosterol  ergosterol).
 High dose: direct damage
Selective Toxicity: Binds fungal demethylase more than human (although both have this enzyme)
Toxicity: GI distress, rash, hepatotoxicity, drug interactions (CYP3A4 inhibitor)

DRUG ORAL ABSORPTION METABOLISM EXCRETION INDICATIONS

Alternative to amphotericin B
Ketoconazole Effective Hepatic Urine
(systemic/mucocutaneous fungal infections)
Good; Urine (80% dose No postantifungal effect; fungistatic.
Mostly non-
Fluconazole independent of excreted in urine 1. Maintenance cryptococcal meningitis
hepatic
gastric acidity unchanged) 2. Prophy for Candida (transplant, etc.)
Erratic, better Systemic; fewer side-effects than ketoconazole
Itraconazole Hepatic only Urine + bile
with acid/food (but still hepatotoxic)
80-90%, better on 1. Invasive aspergillosis
Voriconazole Hepatic only Urine + bile
empty stomach 2. Candidemia
Ketaconazole has shortest half-life (~12h); others in 20-50h range

Allylamines (ergosterol biosynthesis)

naftifine Mechanism of Action: Allylamine antifungal drug. Inhibits ergosterol biosynthesis.
Effects: Inhibit squaline-2-3-epoxidase (earlier step in ergosterol biosynthesis than azoles); lead to membrane
terbinafine disruption and leakage of small molecules.
Selective Toxicity: Highly selective for fungal squalene epoxidase over human (no effect in vivo on cholesterol
biosynthesis
Indications: Candida, etc.
Administration: Topical (+oral for terbinafine)
Other: terbinafine is active ingredient in Lamisil®

Target: nucleotide metabolism (pyrimidine analogs)

Flucytosine Mechanism of Action: Pyrimidine analog antifungal agent. Active form interferes with nucleotide metabolism
(5-FC) Effects: Converted to 5-FU in fungi by cytosine deaminase. 5-FU has two roles:
1. metabolized to 5-FUMP, incorporated into fungal mRNA, interferes with protein synthesis
2. 5-FUMP ; 5-dUMP via ribonucleotide reductase; inhibits thymidylate synthase
Selective Toxicity: Human cytosine deaminase can't deaminate 5-FC (note that fungi and GI FLORA can!)

Indications: systemic Candida/Cryptococcus infections

Administration: co-administered with amphotericin B to combat resistance
Toxicity: generally well tolerated but:
 bone marrow depression,
 GI distress (gut flora killed);
 reversible hepatotoxicity
Resistance: MAJOR PROBLEM - develops very quickly with monotherapy

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 Target: microtubule formation
Griseofulvin Mechanism of Action: Antifungal agent; Interferes with microtubule formation
Effects: actively transported into fungal cells; disrupts microtubules (mitotic & cytoplasmic), cell cycle arrest at
mitosis, formation of multinucleate cells.
Selective Toxicity: Humans don't actively transport into our cells

Indications: Severe infection of hair, nails, palm, soles (concentrates highly in keratin layers)
Administration: Almost complete distribution; goes to keratin layers
Toxicity: Relatively safe (GI distress, temporary headache)

Target: cell wall biosynthesis

Caspofungin Mechanism of Action: Antifungal agent. Inhibits cell wall biosynthesis
Effects: irreversible inhibitor of 1,3-beta-D-glucan synthase (makes glucan polymers for fungal cell wall); fungicidal
Micafungin Selective Toxicity: Humans don't have cell walls; fungi need glucan polymers for structure & viability
Indications:
Anidulafungin  Caspofungin: Salvage therapy for invasive aspergillosis; esophogeal candidiasis, candidemia. Used when
ampho B, others don't work.
 Micafungin: prophylaxis of candidiasis in BMT recipients
 Anidulafungin: Tx of candidemia
Toxicity: Important (limits usage, 14% of recipients). fever, nausea, vomiting, infusion site complications
Resistance: No cross-resistance with other classes

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 Chemotherapy of Parasitic Infections
1/3 of world’s pop has parasites. 1:5 Americans! NO VACCINES so you have to use drugs for prophylaxis & treatment
Can classify as protozoa or helminths, or (more useful for pharm): Gastrointestinal vs Tissue/blood

Selective toxicity of antiparasitics (4 mechanisms)

1. Parasite location
A good antiparasitic drug:
a. if in the lumen of the bowel only, use a luminal agent that’s not
 Safe
absorbed (won’t hurt host cells!) (widespread use / prophy)
2. Differences in host/parasite metabolic pathways  Orally effective
3. Differences in isofunctional enzymes  Cure in 1 dose
4. Concentration of drug by parasite  Cheap

Mechanisms of actions for antihelminthics (2)

Note: adult worms don’t multiply in humans
 if you can get them to stop moving & hanging on, your body can flush ‘em out
 Worms have complex nervous systems; need active motility to resist expulsion by peristalsis

2 Targets: motility & energy generation

1. Parasite motility
pyrantel Mechanism of Action: Antihelminthic agent. Ach analog; neuromuscular blocking agent & Ach inhibitor
(causes spastic paralysis & constant muscle contraction of worm)
Effects:Worms can't resist bowel peristalsis; get swept out
Selective Toxicity: Luminal agent (poorly absorbed) - only affects parasites

Indications: Ascaris infection (helminths)

Administration: PO

praziquantel Mechanism of Action: Antihelminthic agent. Causes tetanic contraction of schistotomes (alters Ca
transport) & alters membrane integrity
Effects: Worms can't resist bowel peristalsis; get swept out to liver/lungs (portal circulation from gut or
systemic from bladder area). Surface of worm disrupted then, leading to death.
Selective Toxicity: unknown (NOT LUMINAL)

Toxicity: frequent GI/CNS but mild

Indications: Cestodes / trematodes (schistosomiasis & tapeworms - taenia solium, etc.)

2. Parasite energy generation

Enteric helminths live in anaerobic environment, so they have a special, different way to get energy:
 Transport glucose across membrane; different end of glycolysis (malate) & Krebs-cycle type thing
 Uses succinate dehydrogenase in respiratory chain (reverse direction from humans: fumaratesuccinate)
 Both the transporter & the succinate DH enzyme are different isoforms in parasites

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Benzimidazoles:
albendazole Mechanism of Action: Antihelminthic agent.
 Block glucose transport
mebendazole  inhibit succinate dehydrogenase activity; an enzyme used in parasite's respiratory chain.
 (also disrupt microtubules selectively)
Effects: No energy for parasites; die & get swept out

Selective Toxicity: Helminths have different metabolism because they're anaerobic; parasitic isoforms are
different for these enzymes than humans'.
 Albendazole: Variable absorption (good to get more coverage; bad because of human
interactions - not a luminal agent)
 Mebendazole: Luminal agent (good absorption
Indications:
 Both: Gut organisms (enterobius, ascaris, trichuris, hookworm)
 Albendazole: tissue too (strongyloides, tapeworm which have tissue parts of life cycle)
Toxicity: Potent teratogen in animals. Don't give to pregnant women. Minimal otherwise
Administration: PO

Gut-dwelling Can go to Tissue

Trematode Cestode
Enterobius Trichuris Luminal?
Ascaris Hookworm (Flukes) (Taenia sp.)
(pinworm) (whipworm)
(Strongyloides) (Tapeworm)
Albendazole +/- absorption
Mebendazole Luminal
Pyrantel Luminal
Praziquantel NO

Classes of antimalarial drugs (3)

Malaria: 100+ countries where P. falciparum (most important) is chloroquine resistant
 all through Africa, Asia, S. America
 Important in USA too: 73 cases in MD last year (more than meningococcus!)
Remember life cycle: sporozoites enter; go to liver, can be hypnozoites in vivax or ovale, form schizonts which burst & release
merozoites, which attack RBC, forming erythrocytic schizonts, which burst in a periodic manner, with more merozoites leaving
(periodic fever); some change to gametocytes, which can be transmitted via new mosquito

 Important: ASYMPTOMATIC until RBC START BURSTING

Note that no drugs have Sporozoite Liver  RBC

activity against all 4 phases  Initial Hypnozoite Asexual Gametes
 Chloroquine
Class I: Asexual RBC form ONLY  Mefloquine
 can’t truly prophylax (need  Quinine
infection to RBC stage to  Fansidar
Class I

start killing) (pyrimethamine +

sulfadoxine)
 Need to start before,
 Coartem
continue through, and
(armether +
continue 3wks after lumefantrine)
exposure for prophylaxis  Tetracyclines
(organisms would have to Class II Primaquine
reach RBC stage to be Atovaquone +
killed by drug) Class III
Proguanil

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Class II: opposite of Class I
 Prophylaxis only: can’t use in symptomatic patient (no effect on RBC stage)
 Can use primaquine to eradicate latent hypnozoites (use if worried about vivax/ovale exposure)

Class III: treatment & prophylaxis (liver stage & asexual stage)

Molecular mechanisms of action: chloroquine, atovaquone/proguanil

4-subsituted quinolones (chloroquine, mefloquine, quinine)

Heme biosynthesis: When Hb is broken down; heme is formed (toxic). Humans & plasmodia (feed on Hb) both have
mechanisms to detoxify
 Humans: break down via heme oxygenase to make bilirubin & excrete
 Plasmodium: no heme oxygenase: form heme polymers (visible as “malaria pigment” or “hemozoin” in
plasmodia).
 Chloroquine blocks this breakdown; heme accumulates; plasmodia die
o Resistance: enhanced efflux mechanisms

chloroquine Mechanism of Action: Antimalarial drug. Inhibits heme detoxification in plasmodia

Effects: Inhibits formation of heme polymers in plasmodia, leading to buildup of toxic heme
Selective Toxicity: Humans use heme deoxygenase to make bilirubin & excrete (different pathway).
Concentrated 100-200fold in infected RBC

Indications: First line for ovale & malariae

Toxicity: Retinopathy (>100g cumulative dose, permanent)
Resistance: Widespread (more common than not: Sub-saharan Africa, South America, SE Asia).
Mutations in transporter proteins (enhance efflux)
Other: Cheap & available

Atovaquone/proguanil: synergistic against malaria parasites in vivo

1. Atovaquone: Binds cytochrome b in P. falciparum; inhibits mitochondrial electron transport
a. Pyrimidine synthesis inhibited
b. Mitochondrial membrane potential collapses
c. Resistance is rapid if monotherapy
2. Proguanil: metabolized to form cycloguanil, which selectively inhibits dihydrofolate reductase
3. Synergy: Not totally known; probably based on collapse of mitochondrial transmembrane potential (not
pyrimidine synth in experiments although that would be logical)

Antimalarial chemotherapeutic regimens

General principles to keep in mind:
Class Drug Use Notes
Cheap, available
I Chloroquine Ovale/malariae malaria
Widespread resistance for falciparum
Prophy against chloroquine-
I Mefloquine CNS toxicity prevents tx of established infection
resistant falciparum
Old; Quinidine is stereoisomer (can use in a pinch)
I Quinine Tx of chloroquine-resistant
IV for serious infection
falciparum malaria
I Coartem Two-drug combo; non-synergistic
Active against liver hypnozoites (only one)
II Primaquine Add for Vivax/ovale
Hemolytic anemia in G6PD-deficient pts!
Atovaquone + Proguanil
III Tx of MDR falciparum More expensive; synergistic
(Malarone)

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Situation Treatment
Prophylaxis Before, during, 3wks after
 Chloroquine if sensitive; malarone, doxycycline, mefloquine if resistant
 Add primaquine if exposure to vivax/ovale (test for G6PD 1st)
Mild/moderate infection ORAL
 Chlorquine if sensitive
 Malarone [or Coartem or quinine (+doxy/tetra/clinda)] if resistant
 Add primaquine when recovered if exposed to vivax/ovale (test for G6PD 1st)
Severe illness IV
 Quinidine or quinine + (doxy/tetra/clinda)
 Add primaquine when recovered if exposed to vivax/ovale (test for G6PD 1st)
Note: only 15-30% US travelers take malaria prophy, docs usually get it wrong

Other protozoal infections (metronidazole)

Metronidazole:
metronidazole Mechanism of Action: Anti-protozoal & anti-anaerobe antibiotic.
 When two nitro-radical anion forms collide, they create a reactive complex that causes
alkylation & strand breakage of DNA
Selective Toxicity: Only works against anaerobes:
 has aromatic NO2 group that accepts an electron from reductive metabolism process
(production of ferredoxin), generating nitro-radical anion only in anaerobes
Indications: Protozoa + anaerobes.
 Trichomonas vaginalis Entamoeba histolytica, anaerobes; off-label for Giardia & H. pylori.
Toxicity:
 Genetic toxicity (? - controversial).
 GI common (nausea, metallic taste, disulfiram-like rxn with alcohol),
 Neuro (headache, ataxia, peripheral neuropathy, seizures - can be irreversible but rare).
 Avoid in pregnant/lactating women
Other: Prefers organisms with high A/T content in their genomes. Penetrates well into abscess cavities,
CSF, bile, bone, placenta, milk. Excreted by kidneys (modify for renal failure)

Anti-amebics
3 things amoebae can do:
1. Hang out as cysts (infective form)
2. Turn into trophozoites but hang out in lumen (commensal)
3. Invade as trophozoites (flask shaped ulcers, etc.)

Infection Treatment
Asymptomatic (luminal carrier) Luminal agent only Paromycin, diloxanide fuorate
Symptomatic (tissue invasion) Luminal agent + tissue agent Metronidazole, tinidazole

Pentamidine
pentamidine Mechanism of action: Active transport & accumulation in parasites.
 Activity is multifactorial: disorganize mitoDNA, inhibit mito Topo, bind ribosomes, inhibit
phospholipid synth, etc.
Indications: T. brucei, Leishmania, Blastomycosis, Babesia, P. jiroveci.
 Aerosolized form recommended for PCP prophylaxis in HIV patients (second line because of
toxicity for Tx behind TMP+SMX)
Toxicity: severe in 55% AIDS pts with PCP. leukopenia, azotemia, hepatitis, unpredictable hypoglycemia
(insulin similarities), others.
Other: Structural analog of synthalin (synthetic insulin)