Micro2800: Microbial Metabolism,

Antibiotics, & Microbial Control

Chap 10

Dr Jason Furrer, Ph.D.

 The Metabolism of Microbes
Metabolism: All chemical reactions and physical
workings of the cell to either gain or use energy

Comprised of 2 reaction types:

Anabolism: also called biosynthesis- any
process that results in synthesis of cell
molecules and structures (usually requires
energy input)
Catabolism: the breakdown of bonds of
larger molecules into smaller molecules (often
release energy)

Functions of metabolism
Assembles smaller molecules into larger
macromolecules needed for the cell
Degrades macromolecules into smaller
molecules and yields energy (ATP)
Produce VFs and other needed processes
Ancient Egyptians were among the earliest peoples to
use fermentation to brew their own beer... Awesome.
 Boring!
Goal metabolism section is NOT to get you to memorize chemical
pathways...

Why we need to know about bacterial metabolism:

Identification: Certain bacteria can be IDd by what they use/refuse
e.g., Neisseria gonorrheae uses only glucose, while Neisseria
meningitidis uses glucose & maltose
e.g., anaerobic vs aerobic bacteria

Control: Knowledge about metabolism can be useful to inhibit microbes

e.g., Providing or limiting nutrients required for growth
Common mechanism for several antibiotic categories

Similarity: What things we use/do, they do also... and more!

Unity of biochemistry natural laws
Whats good for us is good for them (if only the converse was true!!)
Variations in pathways, but genes highly conserved
REPLICATION

Processes &
Disease
 Metabolism Basics: Enzymes
Protein biological catalysts that increase the rate of a chemical reaction without
becoming part of the products or being consumed in the reaction
99% of all metabolic reactions require enzymes
Can also be a measure of cellular dysfunction when assayed
For bacteria, many enzymes are released from the cell as VFs

Can be classified as simple or conjugated

Simple: consist of protein alone
Conjugated: contain protein and nonprotein molecules (cofactors)
Cofactors = organic molecules (coenzymes) or inorganic elements (metal
ions)
 Metabolism Basics: Cofactors
NON-ACTIVE SITE bindings
Often responsible for
configuration changes to enzyme

May keep in off/on modes

Metals: Fe, Cu, Mg, Mn, Zn, Co

- Used to activate cellular
enzymes

Coenzymes: Vitamins
- Most derived from vitamin B
- Can act as temporary
electron carriers

- **Make processes more

energetically/enzymatically
possible & hence growth/
division/repair/etc
- Consider emergen-c or
other superdose vitamins as
potential, but not directed
 Application:
Stopping Bacterial Enzymes
 Controlling Microorganisms: Definitions
How do we & other staff keep the hospital CLEAN
Sterilization = complete removal/destruction of all viable microorganisms,
including non-active forms

Disinfection = reduction in number of majority growing/active microbes, but not

all

Aseptic/Antisepsis/Degerming = reducing number of total organisms, best

referred to as: as cleanly as possible (esp for tissue)

Compounds or practices to achieve these goals:

Physical = heat, cold, radiation, drying, filtration, osmotic pressure
Chemical = um. chemicals.
 Physical Control of Microorganisms
Heat: boiling, pasteurization, ovens DISINFECTS
AUTOCLAVING (heat + steam + pressure) STERILIZES

Cold: chilling, freezing MICROBIOSTATIC (does not kill, just slows growth...)

Processed: filtration, additives/preservatives DISINFECTS

Radiation: gamma, Xray, or UV exposure (breaks DNA) STERILIZES

Common for meats & foods as well as medical products
 Chemical Control of Microorganisms
Chemical agents classified by chemical nature/compound
Can be microbiocidal or microbiostatic, classed with hi-, med-, or low-level activity
Impacted by: # of organisms, material applied to, soln strength, and
EXPOSURE TIME

Halogens = Chlorine (bleach), iodine/iodophores (betadine)

Phenols = ringed compounds; general disinfectants for surfaces (Lysol)
Peroxides = sterilants (good, but breakdown); form oxygen radicals vs DNA, e.g., H2O2
Alcohols = dissolve lipids, impact proteins/enzymes, dehydrate... Concentration
important, generally microbiostatic
Detergents = soaps cause membrane rupture and mechanical stripping
Quats and chlorhexidine
Aldehydes = potent, but unstable and hazardous sterilants (formaldehyde, gluteraldehyde)
Most common compounds for wiping rooms down, etc...
 Other Antimicrobials In Use:
Probiotics = live microorganisms, which when administered in adequate
amounts, confer a health benefit on the host
aka Microbial dietary adjuvants
Microbes added to diet to provide health benefits beyond basic nutritive value
FDA: must be alive, must be safe, must deliver a measured physiological benefit, are not restricted to food/oral delivery, survival or impact on
normal flora shouldnt be required...

Most probiotics are gastrointestinal (food), but also skin, oral, and urogenital
***NOT A FEASIBLE ALTERNATIVE yet***
 Use of Probiotics is NOT Universally Good
http://usprobioticguide.com
Literature and peer-reviewed science on which works well for what
 Discussion Question:

Define ANTIBIOTIC and explain

how they function...

How are these dierent from the

previous compounds we talked
about?
 Notes from My Wife...
Antibiotics:
Often will start, then add something/modify regimen -- Most worried about getting it
started, doing it the right way, make sure not allergic to it, make sure its compatible with
other things running -- why are we giving drugs at all, what are we treating? -- needing
to tell families what you start and what you are treating -- maybe mechanisms of
action for antibiotics are neglected compared to other drugs that are given -- thinking
about the other processes (save that for pharmacology) and common dosages

Most commonly prescribed: Zosyn (pipericillin + tazobactam) for just about anything as the
starter antibiotic -- Kefzol is the standard post-op antibiotic @ Boone -- Vanc as maybe
30% of all that we hang, seems like its pretty often -- When you hang Vanc, you have to
flush every little bit out of the bag, then add 20cc to get every last drop -- try and get
everything to pts ON TIME -- try hard (well, pharmacy...) to meet therapeutic level --
measure peak & trough levels
 Antibiotic Factoids:
Global market for bacterial antibiotics = ~$25-30 billion
Vs antivirals and antiparasitics and drugs...

Best-selling antibiotic = Levaquin (Levofloxacin by Ortho-McNeil/J&J)

Widest used antibiotics:
Zithromax (azithromycin, Z-paks), Amoxil (amoxicillin), Keflex (cephalexin)
Augmentin (amoxicillin + clavulanate)

Antibiotics are common metabolic products of bacteria and fungi

Used in the environment to outcompete each other...
Bacteria: Streptomyces and Bacillus
Molds: Penicillium and Cephalosporium

About 260 different antimicrobials classified in 20 families

Largest number of antimicrobials are for bacterial infections

We create new antibiotics by altering the structure of naturally occurring antibiotics

Search is on for new metabolic compounds with antimicrobial effects
 THE Principle of Antimicrobial Therapy
Goal of antimicrobial chemotherapy: administer a compound to an
infected person, which destroys the infective agent without harming the
hosts cells
Selective toxicity
Worries & Ideals: chart below + dosage, pharmacokinetics, side effects/allergy
**Difference between ANTIBIOTIC and MEDICATIONS (drugs)!
 Antibiotic Classifications & Descriptors

Bacteriocidal Antibiotics:
Kill bacteria
Used when host function is compromised
Bacteriostatic Antibiotics:
Inhibit bacteria
Used when host function is good
Important to consider what you want to do the bacteria...

Broad Spectrum Antibiotics: Effective against many types

Narrow Spectrum Antibiotics: Effective against few types
SpOA = Spectrum of activity
FLEXIBLE AND BREAKABLE RULES OF THUMB ONLY...
ANYTHING or EVERYTHING could have resistances that break SpOA

What is PEN? What is TET?

Spectrum of Activity
 A Target is a Target is a Target...
These things are NON-DISCERNING
chemical compounds... they obey only
biochemical rules

Normal Flora is normal

Good help keep bad in check with natural
sources of antibiotics and growth restrictions
BUT, have the same basic structures!

Broad-spectrum antimicrobials tend to destroy

pathogens, but also beneficial species
Saved by sheer number & previous exposure/
resist
Even small shifts can produce
OPPORTUNITY.
Extended course antibiotics or overgrowth of
pathogens = Superinfection
Diarrhea, secondary infections, etc!
 Safety: Antibiotic Amounts
Establish 3 critical need to knows
Minimum inhibitory concentration (MIC)
Lowest concentration of antibiotic to slow bacterial growth

Minimum bacteriocidal concentration (MBC)

Lowest concentration of antibiotic to kill bacteria

Therapeutic Index (TI)

aka therapeutic window)
Ratio of Max. safe antibiotic amount to MIC
High ratios = Good, Low ratios = Bad

TRADEOFFS of antibiotics -- Activity vs toxicity+safety

TOXICITY = 2 possibilities:
Accumulation to levels that result in compromise
of normal host cellular fcn/process (see above)
Cross-reaction (see selective toxicity, often
consequence of accumulation)
 Safety: Antibiotic Side Effects
Determining between allergy and side effects
S&S are indeed shared, so cant just assume...
BUT, 25% of patients claim allergy to antibiotics
10-15% claim PEN allergy
~1% actually show reactions from further testing!!

Side effects happen as PROCESSING occurs - causes detrimental or toxic

metabolites to host processes or impacts normal flora, but
NOT typically the antibiotic targeting us!!
THESE ARE CHEMICALS THAT DONT BELONG TO US.
Normal effects = soft stools or mild diarrhea, mild stomach upset
More serious effects = Vomiting, severe watery diarrhea and abdominal
cramps, superficial skin rash, vaginal itching/discharge, white patches on the
tongue (thrush)
 Safety: Antibiotic Allergies
**Mythical synergy between antibiotics and immunity body wants it gone!
Allergy: Immune system recognizing an antibiotic as foreign and
stimulates a response directly against it
Can be mild or severe reactions such as skin rash/hives, respiratory inflammation
(SoB), swelling, fainting, and anaphylaxis
Depends of route of administration and travel thru body
 Examples: Antibiotic Side Effects
Alcohol -- processed in liver along with antibiotic, risk of toxic metabolites or inactivation of antibiotic -- metronidazole (Flagyl), tinidazole (Tindamax) and trimethoprim-
sulfamethoxazole (Bactrim) may result in a more severe reaction. Drinking any amount of alcohol with these medications can result in side effects such as flushing, headache,
nausea and vomiting, and rapid heart rate... Keep in mind that some cold medicines and mouthwashes also contain alcohol!!

Combined oral contraceptives -- Antibiotics may cause youroral contraceptive pill to be less effective!

Medications by specific class of antibiotic:

Penicillin -- skin rash with methotrexate (used to treat some types of cancers andsevere autoimmune conditions such as psoriasis) or allopurinol (used to treat gout)

Cephalosporins -- not be suitable to take if you are also taking blood-thinning medications such as heparin or warfarin

Aminoglycosides -- increased risk of damage to kidneys and hearing if you are taking one or more of the following medications:

antifungals, cyclosporin (used to treat Crohns disease or given for organ transplants), diuretics (used to remove water from the body), or muscle relaxants
***However, the risk of kidney and hearing damage has to be balanced against the benefits of using aminoglycosides to treat life-threatening conditions.

Tetracyclines -- high interactivity:

vitamin A supplements, retinoids such as acitretin, isotretinoin and tretinoin used to treat severe acne, blood-thinning medication, diuretics, kaolin-
pectin and bismuth subsalicylate used to treat diarrhea, diabetes meds such as insulin, atovaquone used to treat pneumonia, antacids used to treat
indigestion & heartburn, sucralfate used to treat ulcers, lithium used to treat mental disorders/depression, digoxin to treat heart rhythm disorders,
methotrexate, strontium ranelate used to treat osteoporosis, colestipol or colestyramine used to treat high cholesterol, ergotamine and methysergide used to
treat migraines

Macrolides -- combine a macrolide with any of the following medications risks heart problems:

terfenadine, astemizole and mizolastine (antihistamines for allergic conditions such as hay fever), amisulpride used to treat episodes of psychosis, tolterodine
used to treat urinary incontinence, or simvastatin used to treat high cholesterol

Fluoroquinolones -- any of the following medications:

theophylline used to treat asthma and also found in some cough and cold medicines, thenon-steroidal anti-inflammatory drug (NSAID) painkillers
such as ibuprofen, ciclosporin, probenecid used to treat gout, clozapine used to treat schizophrenia, ropinirole used to treat Parkinson's disease, tizanadine
used to treat muscle spasms, glibenclamide used to treat diabetes, cisapride used to treat indigestion, heartburn, vomiting or nausea, tricyclic antidepressants, such
as amitriptyline, corticosteroid medications for inflammation, antacids, zinc supplements, some types of multivitamin supplements -- Some
fluoroquinolones can intensify the effects of caffeine, which leads to irritability, restlessness and insomnia
 Vancomycin Red Man Syndrome
VANC is often used in intensive care units. It is the drug of choice for MRSA, and resistant strains of S.pneumoniae.
VANC can cause two types of reactions, red man syndrome (RMS) and true allergy/anaphylaxis (T1HS).
Both rxns are from release of large amounts of histamine (mast cells)
RMS = accidental stimulation of mast cell receptors by VANC, but NOT truly targeting VANC
T1HS (allergy) = immune system directly activated against VANC
Signs of RMS appear about 410 min after an infusion started or may begin soon after its completion.
It is most associated with rapid (<1 hour) infusion of the first dose of VANC. Most hospital protocols require VANC to be infused
over 60 min. RMS has been linked to IV, intraperitoneal, and oral administration of VANC
RMS has often been associated with rapid infusion of the first dose of the drug and was initially attributed to impurities found in VANC
preparations (Mississippi Mud). Even after improvement in vancomycin's purity, however, reports of the syndrome persist.
Incidence varies, but RMS occurs more in patients < 40, particularly in children
Also with ciprofloxacin, amphotericinB, rifampcin and teicoplanin. RMS is amplified if these antibiotics are combined with VANC or
with each other. RMS is also magnified in patients receiving VANC and opioid analgesics, muscle relaxants, or contrast dye
because these drugs can also stimulate histamine release.

RMS = pruritus (itch) often with an erythematous rash that involves the face, neck, and upper torso. Less frequently,
hypotension and angioedema can occur. Patients commonly complain of diffuse burning and itching and of generalized discomfort. They can
rapidly become dizzy and agitated, and can develop headache, chills, fever, and paresthesia around the mouth. In severe cases, patients
complain of chest pain and dyspnea. In many patients, the syndrome is a mild, evanescent pruritus at the end of the infusion that goes
unreported.

The effects of RMS can be relieved by antihistamines or pretreatment + discontinuation of the vancomycin
infusion
https://app.figure1.com/images/5768535933df203b4e4e9df3
Vancomycin Red Man Syndrome
 Stevens Johnsons Syndrome (SJS/TEN) - T4HS

SJS = rare, serious disorder in which skin and mucous membranes react severely to a medication or
infection.
The condition is called TEN when >30% of the body surface area is involved and SJS with <10%
of body surface area!

Often begins with flu-like symptoms, followed by a painful red or purplish rash that spreads
and blisters, eventually causing the top layer of skin to die and shed
Split between derm/epi layers (NB: SSSS = split within epidermis)
Most associated with Nonsteroidal anti-inflammatory drugs (NSAIDs), and B-lactams
Reaction of Tcells to accumulation of chemical compound/drug/antibiotic on
skin proteins
Type 4 hypersensitivity (more closely related to autoimmunity than allergy)

Initial SJS = non specific (fever, sore throat, cough, burning eyes)
Facial or tongue swelling, Hives, Skin pain, red/purple skin rash that spreads within hours to days
Blisters on skin and mucous membranes, especially mouth, nose and eyes, sloughing of skin
SJS/TEN
 Interactions Between Antibiotic & Microbe:
How These Work...

Bacterial Antibiotics work under 4 major mechanisms

Termed Classes or Families
Lots of overlapping

Inhibition at cell wall level

Inhibition of protein synthesis
Inhibition of metabolic synthesis (antimetabolites)
Inhibition of nucleic acid structure and function
As a general rule of thumb... Walsh, C.T., Antibiotics (2003) ASM
Bacterial
Antibiotic
Families
 Cell Wall Synthesis Inhibitors

Family 1 -- Beta-lactam antibiotics

-cillin compounds e.g. - Penicillin, Amoxicillin, etc

-lactam ring functional group

(garage + house)

Basic mechanism = inhibit peptidoglycan synthesis

In depth = Prevents cross-linkage of NAM/NAG subunits by
inhibiting bacterial transpeptidase enzymes

No effect on plant or animal cells

Effective only when bacterial cells are growing!


Walsh, C.T., Antibiotics (200

 -Lactam Antibiotics
SpOA for -cillins = best effective primarily against Gram (+) organisms
Why??

Penicillins (G & V) = basics

Ox/Clox/Meth/Naf (single syllables) = anti-Staphylococcals
Ampicillin (Unasyn) and amoxicillin (Amoxil,Trimox) = extended spectra, used in many infections
Carbeni/pipera/ticar/mezlo = anti-Pseudomonals or resistant Gram(+)s

Carbepenem family with large bulky side chains to protect -lac ring/bond, often good -lac of
choice for G(-)s
e.g., Imipenem -- similar to PEN, but resistant to -lactamase (though NOT unbreakable, see
NDM-1 superbugs)

Adverse Effects:
Allergic reactions (Real, but surprisingly low...) & anaphylactic shock (varying degrees)
Diarrhea
Nephritis (especially for methicillin!!)
Neurotoxicity (esp for neonates)
Platelet disfunction
 Cell Wall Synthesis Inhibition

Family II -- Non--Lac Cell Wall Synthesis Antibiotics:

Slightly different mechanisms or targets

Vancomycin -- interferes with alanine-alanine bridges in PPG

SpOA = against almost all Gram(+), but NOT Gram(-) organisms
A big gun antibiotic, very powerful and effective... (think: MRSA, etc)
A last line antibiotic, where if resistance grows, WE ARE IN TROUBLE. PERIOD.
Side effect: Red Man Syndrome

Isoniazid and ethambutol -- disrupt formation of arabinogalactan-mycolic acid (PPG

equivalent) in Gram NA species
SpOA = Mycobacteria tuberculosis primarily, but can also be used for other G(na) like
Mycoplasma pneumoniae, Moraxella, etc
 Cell Wall Synthesis Inhibition

Family III -- Cephalosporin antibiotics

STILL has -lactam ring functional group

(2 sided R-group house + basement...)

Also prevent cross-linkage of NAM/NAG subunits by inhibiting

transpeptidases, but better targeted than classic -lactams
Generations allow for specialization of treatment
Each generation active against different organism classes
 Generations of scaffold tailoring

 Cephalosporins
SpOA = HEN PEcK or HEN PPEcK(Haemophilus influenzae, Enterobacter spp,
Neisseria spp, Proteus, E.coli, Klebsiella) + Pseudomonas as the ExtraP...

1st Gen: e.g., Cephalexin (Keflex)

SpOA = Gram(+) and HEN

2nd Gen: e.g., Cefuroxime (Zinacef)

SpOA = Fewer Gram(+) and HEN PEcK

3rd Gen: e.g., Ceftazidime (Fortaz), Ceftriaxone (Rocephin)

3G & up can cross the blood-brain barrier due to lipid solubility
SpOA = Fewer Gram(+) and HEN PEcK

4th Gen: e.g., Cefepime (Maxipime):

SpOA = Fewer Gram(+) and PPEcK
 Other Antibiotics Acting on Bacterial
Membrane Disruption

Grouped here for easiest understanding, but N-O-T classic PPG attackers
Antibiotics incorporated into cytoplasmic membrane & damage/integrity

Bacitracin + Polymyxin B (SpOA = simple Gram+/- organisms)

Pore formers via strong hydrophobic interactions
Nephrotoxic, so topical use only (if Neomycin added)

Daptomycin (SpOA = Gram+ organisms, effective vs Staphs)

lipopeptide binds to the membrane, causes rapid depolarization, and loss
of membrane potential
In turn, inhibition of metabolism (protein, DNA and RNA) processes,
which results in bacterial cell death.
 Mechanism II:
Protein Synthesis Inhibitors

Prokaryotic ribosomes are 70S (30S and 50S subunits)

Eukaryotic ribosomes are 80S (40S and 60S)
Universal (broad) target as all bacterial cells require ribosomes
High concentrations may mis-target to eukaryotic

Ribosomes essential for translation of mRNA proteins

Can attack either ribosomal subunit to shut down

No translation No protein synthesis No growth

 Remembering Ribosome Inhibitors:
CLEAn TAG Mnemonic

If the whole ribosome is Home plate

Top of plate is 50S

Bottom of plate is 30S

My way: big word inhibits big subunit,

small word inhibits small subunit...

50S

30S
 CLEAn TAG mnemonic
Antibiotics: Modes of action

CLEAn (the Macrolide antibiotics):

C = Chloramphenicol
L = Lincomycin
(CL = CLindamycin)
E = Erythromycin
A = Azithromycin
Walsh, C.T., Antibio

TAG:
T = Tetracycline
A = Aminoglycosides
 CLEAn

C = Chloramphenicol

SpOA = VERY broad spectrum antibacterial, but high side effects/Xreact

RESTRICTED to life-threatening infection w no alternatives

Adverse effects: bone marrow suppression, aplastic anemia, grey baby

syndrome, leukemia

L = Lincomycin and derivative CLindamycin (Cleocin)

SpOA = Used for anaerobic and severe aerobic infections (e.g.,

streptococcal toxic shock syndrome)

Adverse effect: pseudomembranous colitis (Clostridium difficile)

 CLEAn

E = Erythromycin (macrolide family antibiotic)

Derivative macrolide antibiotics: Azithromycin (Zithromax, Z-Pak,

Zmax); Clarithromycin (Biaxin)

SpOA = Gram(+), Gram(NA) like Mycoplasma pneumoniae, Legionella

pneumophila, Chlamydia, Syphilis, intracellular bacteria

Less active against Staphs and Streps (most hospital strains of Staph are
resistant!!)

Good choice for PEN allergies

Adverse effects: Disrupt normal GI flora leading to diarrhea, nausea, vomiting,

abdominal pain and cramping
 TAG

T = Tetracycline (Brand name: Doxycycline)

1948, @MU! Sanborn Field yielded aureomycin (chlortetracycline)
Very Broad Spectrum -- SpOA includes most Gram(NA), many Gram(+/-)

Low cost, but high adverse effects/Xreactivity

Diarrhea, Stains teeth, Photosensitivity, Liver toxicity, LOTS of interactions
Gastric discomfort but Inactivated by Ca++ (not to be taken with milk or
yogurt)
May be teratogenic for fetuses, passes into breast milk, may affect bone/
tooth/growth development, contraindicated for children under 8
 TAG
AG = Aminoglycoside antibiotics
Gentamicin, Kanamycin,Tobramycin, Neomycin, Streptomycin, Amikacin
SpOA = Mostly for serious Gram(-) infections...
But use is tempered by HIGH toxicity
Cant be taken orally
NOT usable against anaerobic organisms (needs O2 for uptake)

Adverse effects: Nephrotoxicity (kidney failure), Ototoxicity

(Hearing loss), will cross placenta
 Newest Anti-Ribosomals:
Synercid and Oxazolidones

Synercid -- synthetic!
Inhibits the 50S ribosome, inhibiting translation
SpOA = Effective against Staphylococcus and Enterococus species and
against resistant strains of Streptococcus

Oxazolidones
Inhibit the 50S ribosome for protein synthesis initiation
Brand name: Zyvox
SpOA = Used to treat infections caused by two of the most difficult
clinical pathogens: methicillin-resistant Staphylococcus aureus (MRSA)
and vancomycin-resistant Enterococcus (VRE)
Last line for Gram(+), almost no activity in Gram(-)
Mechanism III - Antimetabolite Antibiotics

Exploited when differences exist between metabolic processes of host and pathogen

Most are anti-bacterials (include antivirals MoAs as well...)

Often act in one of the following manners:

Mimics a natural compound, aka competitive inhibition

Shuts down a natural process, aka noncompetitive inhibition

E.g., Bacterial synthesis of folic acid is necessary for DNA replication

(Humans obtain folic acid from diet)

 Bacterial Antimetabolite Antibiotics
Sulfonamides
Sulfa drugs -- Very first modern antimicrobials
Mimic of PABA, necessary for making folate
Folate nucleotides DNA replication
SpOA = Gram(-), Enteric bacteria, Shigellosis, acute urinary tract
infections

Trimethoprim
Inhibits an enzymatic step immediately after the step inhibited by sulfonamides in
the synthesis of folic acid
SpOA = otitis media, urinary tract infections, One of the primary
treatments for Pneumocystis (carinii) jiroveci pneumonia (PCP) in AIDS patients
**Synergistic (given in combination) effects with Sulfa & Trimeth
Brand names: Bactrim, Cotrim, Septra
NOT recommended (although mechanistically safe) during pregnancy

Others (less widely used) = Dapsone, Methotrexate, Pyrimethamine

 Competitive inhibition
(Sulfa looks like PABA)

Antibiotics: Modes

Noncompetitive inhibition
(Trimethoprim stops necessary
DHF reductase enzyme)
 Mechanism IV -- Antibiotic
Inhibitors of
Bacterial Nucleic Acid Synthesis
Quinolones/Fluoroquinolones (-flox antibiotics)
Inhibit prokaryotic DNA gyrase (unwinding), stopping replication
Ciprofloxacin (Cipro) SpOA = prophylaxis, anthrax
Norfloxacin (Noroxin) SpOA = Gram(+/-), Pseudomonas, UTIs Walsh, C.T., Antibiotics (2003) ASM

Quickly cleared in urine...

Levofloxacin (Levaquin) SpOA = Many STD organisms, skin infections,
systemic infections
Nalidixic acid = UTIs (esp G+)

Rifampin
Inhibit action of bacterial RNA polymerase during transcription:
SpOA = Gram(+/-), Mycobacterium tuberculosis
Used in treatment of pneumonia, UTI, gastroenteritis and atypical
pneumonia
 Antiviral Agents
Selective toxicity is almost impossible to achieve because viruses are using host
cells/machinery to replicate
Several antiviral compounds have been developed that target specific points in
the infectious cycle of viruses

Major modes of action:

Slowing/Blocking the transcription and translation of new viral molecules
(usually at level of DNA/RNA synthesis)
Host polymerases are not killed, but slowed (have proofreading)
Viral polymerases have to start over when they incorporate these
dead-end molecules

SpOA = Any virus thats replicating, better selective tox vs RDRP/RDDP

Many Antivirals = Antimetabolite Mechanism

Nucleotide analogs mimic natural A/C/G/T bases, but with altered structures

Competitive inhibitors, each with a Best SpOA polymerase

Incorp causes chain termination and prevents further replication, transcription or

translation of that molecule

Viral DNA polymerase (no proofreading) more likely to incorporate

Your processes more likely to repair... so fairly safe - Potentially teratogenic

or mutagenic...

Viral synthesis more rapid than that of host cells

**DO NOT KILL VIRUSES!!**

SLOW processes to allow immune system to catch up or destroy infected cells

Examples: Acyclovir/Valacyclovir (Valtrex), AZT (Zidovudine), Lamivudine, Ribavirin

Acyclovir,Valtrex, etc AZT, Lamivudine, etc
 Other Antivirals:
Entry/Exit Blockers = Prevent binding to host ligands

Examples: Zanamivir (Relenza)

Act as a competitive inhibitor to host sialic acid or binds neuraminidase,

preventing/entry spread of

[Oseltamivir (Tamiflu) is out!!]

SpOA = Influenza virus (HxNx)

Interferons (IFNs) = Glycoproteins produced by immune cells

Work as noncompetitive inhibitors to convert cells to alternative pathways

that are not as corruptible by viruses

Injections given to those with serious viral infections

SpOA = Hepatitis virus
 Agents to Treat Fungal Infections
Fungal cells are eukaryotic, so present special problems
Majority of antibiotics designed to act on bacteria are ineffective for fungal infections
Similarities between fungal & human cells (=Toxicity)
SpOA = Any fungal forms

Synthetic Azoles (-azole) -- Broad-spectrum antifungal agents also vs ergosterol

Clotrimazole/Miconazole: mainly topical ointments for infections in the skin, mouth, and vagina
(Monistat, Micatin, etc)
Ketoconazole: oral and topically for cutaneous mycoses, vaginal and oral candidiasis, and some
systemic mycoses
Fluconazole: used in selected patients for AIDS-related mycoses, gets to CSF

Amphotericin B
Attack fungal membranes by binding to fungal sterols (ergosterol) & form pores
But can Xreact with human cholesterol if overdosed...
High toxicity
Ampho-terrible

Terbinafine (Lamisil): topical ointments for skin and Nystatin: oral swish/swallow antifungal
Agents to Treat Fungal Infections
 Anti-Parasitic Compounds

Quinine & Derivatives as anti-malarials

Quinine originally extracted from the bark of the cinchona tree
Slows parasitic growth
Replaced by synthesized quinolines (chloroquine and
primaquine) -- less toxic to humans

Metronidazole (Flagyl)** -- note -dazole

Usually for protozoan infections, causes DNA and protein damage
Amoebicide, Giardia lamblia and Trichomonas vaginalis

**Also very good for anaerobic bacterial infections (C.diff!)

 Anti-Helminth Compounds

General MoA -- Energy drainers for worm infections, leads to

paralysis or death of worms and expulsion from body
Nicotinic receptors, cytoskeletal depolarizers, etc

Pyrantel pamoate
Piperazine
Mebendazole & Thiabendazole

SpOA = Good for pinworm and hookworm, some activity on other

roundworms and flat (tape) worms
 Discussion Question:

What is antibiotic resistance and how does it happen?

Vancomycin-resistant enterococci (VRE)

VRE in ICUs

Percent resistant

Opportunistic pathogen in immunocompromised patients, with

high mortality (25%)
Second-most prevalent gram-positive pathogen in U.S.
hospitals
Ammerlaan & Bonten (2006) Clin Microbiol Infect 12 (Suppl 8), 22
http://www.cdc.gov/ncidod/dhqp/nnis_pubs.html
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 Antibiotic Resistances
Resistance: an adaptive response in which microorganisms begin to survive in an
amount of antibiotic that would ordinarily be inhibitory
I hate Hate HATE seeing the patient is resistant to the antibiotic... NO! Thats different -- called tolerance or related to pharmacokinetics!!

DRIVEN BY EXPOSURE, BUT NOT SOLELY DUE TO EXPOSURE!!

Antibiotics select for resistance, they don't cause resistance
ACTIVE process! -- the gun example

ANY antibiotic usage starts selection processes of rare resistant organisms

Resistance is inevitable... Why?? = NF, evolution/mutation, sharing, RANDOMNESS...

Microbes gain resistance to an antibiotic by:

Change the antibiotics target via random mutations
Acquisition of entire new genes that produce anti-antibiotic enzymes/
molecules
Often on plasmids...
e.g., -lactamases & pumps
Find a niche with inaccessibility to antibiotics (e.g., abscess, TB lesion)
 Clinical resistance can emerge rapidly

Year Resistance
Antibiotic Deployed Observed
Sulfonamides 1930s 1940s
Penicillin 1943 1946
Streptomycin 1943 1959
Chloramphenicol 1947 1959
Tetracycline 1948 1953
Erythromycin 1952 1988
Vancomycin 1956 1988
Methicillin 1960 1961
Ampicillin 1961 1973
Cephalosporins 1960s late 1960s
Palumbi, Science 293, 1786 (2001)
 Antibiotic Resistances:
A Cat & Mouse Game...
For every antibiotic we give, the microbes have a chance to change/counter it
Back-and-forth battle for whos smarter

We use -lactams...
Naturally immune bacteria survive or may start to release enzymes that confer
resistance by inactivating antibiotics
e.g., -lactamases (aka penicillinases)
Cleavage of one bond on PEN results in an inactive compound (C=N)

But, were running out of antibiotics, so how can we counterpunch??

Antibiotics still effective if we can just get past the protective molecule!
Combat with additives that then block the bacterial enzymes
Augmentin = amoxicillin + clavulanic acid
Zosyn = piperacillin + tazobactam
 Combination therapy and/or drug cycling

Could new combination therapies open the door to using

compounds with high rates of monotherapy resistance?
 Selecting an Antimicrobial Antibiotic

** THERE IS NO RIGHT ANSWER MANY TIMES... **

Considerations:
Look at S&S and overall medical condition of the patient
Preliminary ID of the etiological microorganism

Choose an antibiotic based on likely organism and experience/likelyhood of

targets as informed best guess
Find the degree of the microorganisms susceptibility to various antibiotics
Take samples, send for analysis
**Test antibiotic susceptibility of microorganisms

Refinement of therapies!!
 Wrapup!
Recall structure/fcn lecture to this one as part of targets!
Major antibiotic families and their basic mechanisms
How bacteria become resistant
How we can test for and interpret antibiotic susceptibility