Beta Lactam Antibiotics

Presentation by:
Saurav Chandra Sarma
Int. Ph.D NCU 3rd Sem.
 Outline
• What is Antibiotic???
• Bacterial cell structure
1

• Beta-lactam Antibiotics and it’s mode of action

• Resistance to Beta lactam Antibiotics
2 • Examples

• Beta-lactamases and its classification

• Proposal
3 • Conclusion.!!!
Antibiotics and it’s Classification
 Antibiotics
•An antibiotic is an agent that either kills or inhibits the
growth of a microorganism.

•Excludes substances that kill bacteria but that are not

produced by microorganisms such as Gastric juices &
Hydrogen Peroxide.

•Also excludes synthetic antibacterial compound such as

sulfonamides.

•Penicillin is the first natural antibiotic discovered by

Alexander Fleming in 1928.
 Classification of Antibiotics
Based on mode
of Action

Bacteriostatic Bactericidal

Based on their
spectrum of
action

Narrow
Broad-spectrum
Spectrum
Source: Google Images
 Types of Antibiotics
(Based on their mode of action)
Bacteriostatic Antibiotics Bactericidal Antibiotics

• Tetracyclines • Penicillins
• Spectinomycin • Cephalosporins
• Sulphonamides • Fluoroquinolones
• Macrolides (Ciprofloxacin)
• Chloramphenicol • Glycopeptides (Vancomycin)
• Trimethoprim • Monobactams
• Carbapenems
 Types of Antibiotics
(Based on their structural similarities)
 Antibiotics: Mode of Action
•Inhibitors of DNA synthesis

•Inhibitors of bacterial protein synthesis

•Inhibitors of bacterial cell wall synthesis

•Interference with metabolism

•Impairment of nucleic acids

Antibiotic Targets

Sourcs: Microbiology: A Clinical Approach

Bacterial Cell structure
Gram positive vs. Gram negative
bacteria

Source: Google Images

Cell Wall

Source: Google Images

 Structure of Peptidoglycan layer

•Peptidoglycan is a carbohydrate composed of alternating

units of NAMA and NAGA.

•The NAMA units have a peptide side chain which can be

cross linked from the L-Lys residue to the terminal D-Ala-D-
Ala link on a neighboring NAMA unit.

Source: Google Images

 Transpeptidase Enzyme
•The cross linking reaction is catalyzed
by a class of transpeptidases known as
penicillin binding proteins

•A critical part of the process is the

recognition of the D-Ala-D-Ala
sequence of the NAMA peptide side
chain by the PBP. Interfering with this
recognition disrupts the cell wall
synthesis.

•β-lactams mimic the structure of the

D-Ala-D-Ala link and bind to the active
site of PBPs, disrupting the cross-
linking process.
Source: Google Images
Transpeptidation mechanism

Source: Google Images

Transpeptidation mechanism

Source: Google Images

Beta–lactam Drugs
 Beta-Lactam Antibiotics

β-lactam ring

•Contains a beta-lactam ring in their molecular structures.

•Nitrogen is attached to the beta carbon relative to the

carbonyl ring and hence the name.
 Classification
•Penicillins

•Cephalosporins

•Other β-Lactam drugs

--Cephamycins
--Carbapenems
--Oxacephalosporins
--β-Lactamase inhibitors
--Monolactams
Beta-Lactam Structure
 How do they work?
1. The β-lactam binds to Penicillin Binding
Protein (PBP)
2. PBP is unable to crosslink peptidoglycan
chains
3. The bacteria is unable to synthesize a stable
cell wall
4. The bacteria is lysed
 Mechanism of β-Lactam Drugs
• The amide of the β-lactam ring is unusually
reactive due to ring strain and a conformational
arrangement which does not allow the lone pair of
the nitrogen to interact with the double bond of
the carbonyl.
• β-Lactams acylate the hydroxyl group on the serine
residue of PBP active site in an irreversible manner.
• This reaction is further aided by the oxyanion hole,
which stabilizes the tetrahedral intermediate and
thereby reduces the transition state energy.
 Discovery of Penicillin(First beta-
lactam drug)

•Discovered in 1928.
• While working in his lab, trying to kill a deadly bacteria,he noticed a
blue mold growing on the dish
•Learned that it was the mold Penicillum Notatum.
•Penicillin is found in this mold.
•Noticed that the bacteria around the mold was dissolving.
Source: Google Images
 How it is was Developed

• For 9 years, nobody could purify the Penicillum Notatum

to get the pure penicillin.
Finally, in 1938, a team of Oxford University Scientists,
headed by Howard Florey and Ernst B. Chain helped to
develop penicillin.
Source: Google Images
 Mechanism of β-Lactam Drugs
• The amide of the β-lactam ring is unusually
reactive due to ring strain and a conformational
arrangement which does not allow the lone pair of
the nitrogen to interact with the double bond of
the carbonyl.
• β-Lactams acylate the hydroxyl group on the serine
residue of PBP active site in an irreversible manner.
• This reaction is further aided by the oxyanion hole,
which stabilizes the tetrahedral intermediate and
thereby reduces the transition state energy.
 Mechanism of β-Lactam Drugs
The hydroxyl attacks the amide and forms a
tetrahedral intermediate.
 Mechanism of β-Lactam Drugs
The tetrahedral intermediate collapses, the amide
bond is broken, and the nitrogen is reduced.
 Mechanism of β-Lactam Drugs
The PBP is now covalently bound by the drug and
cannot perform the cross linking action.
Penicillin
Natural Penicillin
 Penicillin V (Phenoxymethylpenicillin)
EFFECTIVE AGAINST:
• Gram positive + Less effective
against Gram negative bacteria
TREATMENT FOR:
• Tonsillitis
• Anthrax
• Rheumatic fever
• Streptococcal skin infections
CHARACTERISTICS:
• Narrow spectrum
• Should be given orally
• Prone to beta-lactamase
 Penicillin V (Phenoxymethylpenicillin)
EFFECTIVE AGAINST:
• Gram positive + Less effective
against Gram negative bacteria
TREATMENT FOR:
• Tonsillitis
• Anthrax
• Rheumatic fever
• Streptococcal skin infections
CHARACTERISTICS:
• Narrow spectrum
• Should be given orally
• Prone to beta-lactamase
Amino-Penicillin

Ampicillin R=Ph

Amoxicillin R= Ph-OH
 Ampicillin
EFFECTIVE AGAINST:
• Gram positive + Gram negative
bacteria
TREATMENT FOR:
• Ear infection
• Sinusitis
• Urinary tract infections Ampicillin
• Meningitis +
CHARACTERISTICS:
• Broad spectrum
• Can be given orally and
parenterally
Sulbactam
• Prone to beta-lactamase
ll
Unasyn
 Amoxicillin
EFFECTIVE AGAINST:
• Gram positive + Gram negative
bacteria
TREATMENT FOR:
• Skin infection
• Sinusitis
• Urinary tract infections
• Streptococcal pharyngitis Amoxicillin
CHARACTERISTICS: +
• Broad spectrum
• Can be given orally and parenterally
• Prone to beta-lactamase
SIDE-EFFECTS:
• Rash, diarrhea, vomiting, nausea, Clavulanic Acid
edema, stomatitis, and easy
fatigue.
ll
Augmentin
Anti-Staphylococcal Penicillin
 Methicillin
EFFECTIVE AGAINST:
• Gram positive bacteria
TREATMENT FOR:

CHARACTERISTICS:
• Very narrow Spectrum
• Should be given parenterally
SIDE-EFFECT:
• Interstitial nephritis
 Oxacillin
EFFECTIVE AGAINST:
• Gram positive bacteria
TREATMENT AGAINST:
• penicillin-resistant Staphylococcus
aureus
CHARACTERISTICS:
• Very narrow Spectrum
• Should be given parenterally
SIDE-EFFECT:
• Hypersensitivity and local reactions
• In high doses, renal, hepatic, or
nervous system effects can occur
 Nafcillin
EFFECTIVE AGAINST:
• Gram positive bacteria
TREATMENT AGAINST:
• Staphylococcal infections
CHARACTERISTICS:
• Very narrow Spectrum
• Should be given parenterally
SIDE-EFFECT:
• Allergic reactions
• Nausea and vomiting
• Abdominal pain
 Cloxacillin
EFFECTIVE AGAINST:
• Staphylococci that produce
beta-lactamase
CHARACTERISTICS:
• Very narrow Spectrum
• Should be given orally
SIDE-EFFECT:
• Allergic reaction
 Dicloxacillin
EFFECTIVE AGAINST:
• Gram positive bacteria +
Staphylococci that produce beta-
lactamase
CHARACTERISTICS:
• Very narrow Spectrum
• Should be given orally
SIDE-EFFECT:
• Allergic reaction
• Diarrhoea, nausea, rash, urticaria
pain and inflammation at
injection site
 Flucloxacillin
EFFECTIVE AGAINST:
• Gram positive bacteria +
Staphylococci that produce beta-
lactamase
CHARACTERISTICS:
• Very narrow Spectrum
• Should be given orally
SIDE-EFFECT:
• Allergic reaction
• Diarrhoea, nausea, rash, urticaria
pain and inflammation at
injection site
Anti-Pseudomonal Penicillin
 Piperacillin
EFFECTIVE AGAINST:
• Gram positive +Gram negative
CHARACTERISTICS:
• Extended Spectrum
• Should be given
by intravenous or intramuscular injection
SIDE-EFFECT:
• Hypersensitivity
• Gastrointestinal
• Renal
• Nervous system

*Piperacillin+Tazobactam=Zosyn
 Carbenicillin
EFFECTIVE AGAINST:
• Gram negative + Limited Gram
positive
TREATMENT FOR:
• Urinary tract infections
CHARACTERISTICS:
• Highly soluble in water and acid-
labile
SIDE-EFFECT:
• High doses can cause bleeding
• Hypokalemia
 Ticarcillin
EFFECTIVE AGAINST:
• Mainly gram negative bacteria
particularly Pseudomonas aeruginosa
TREATMENT FOR:
• Stenotrophomonas maltophilia
infections
CHARACTERISTICS:
SIDE-EFFECT:
• Diarrhoea
• Bleeding
• Fever
• Fainting
Cephalosporin
These has been conventionally classified into four
generations based on Generation system

• This is based on chronological sequence of development,

but more importantly ,takes into consideration the overall
antibacterial spectrum as well as potency.

• First-generation cephalosporins are predominantly active

against Gram-positive bacteria, and successive generations
have increased activity against Gram-negative bacteria
(albeit often with reduced activity against Gram-positive
organisms).
First Generation Cephalosporins

Cefalothin Cefalexin

Cefadroxil Cefazolin
Second Generation Cephalosporins

Cefuroxime(Oral) Cefotetan
Third Generation Cephalosporins

Cefotaxime Ceftriaxone

Ceftazidime
Fourth Generation Cephalosporins

Cefepime
Carbapenem
 What are carbapenems
• Carbapenems are a class of beta-lactam
antibiotics with a broad spectrum of
antibacterial activity. They have a structure
that renders them highly resistant to beta-
lactamases. Carbapenem antibiotics were
originally developed from thienamycin, a
naturally-derived product of Streptomyces
cattleya.

Dr.T.V.Rao MD 57
 Carbapenems common uses
• Imipenem
– Broad spectrum, covers Gram-positive, Gram-negative
(including ESBL-producing strains), Pseudomonas and
anaerobes
• Meropenem
– Less seizure-inducing potential, can be used to treat CNS
infections
• Ertapenem
– Lacks activity vs. Acinetobacter and Pseudomonas
– Has limited activity against penicillin-resistant
pneumococci

Dr.T.V.Rao MD 58
 Imipenem
EFFECTIVE AGAINST:
• Aerobic and anaerobic, Gram
positive and gram negative
bacteria
CHARACTERISTICS:
• Broad Spectrum
• Intravenous
• Resistant to beta-lactamase
enzymes
SIDE-EFFECT:
• Seizuregenic at high doses
 Meropenem
EFFECTIVE AGAINST:
• Aerobic and anaerobic, Gram
positive and gram negative
bacteria
CHARACTERISTICS:
• Ultra Broad Spectrum
• Intravenous
• Resistant to beta-lactamase
enzymes
SIDE-EFFECT:
• Diarrhoea
• Vomiting
• headache
 Ertapenem
EFFECTIVE AGAINST:
• Gram positive and gram negative
bacteria
CHARACTERISTICS:
• Broad Spectrum
• Intravenous
• Resistant to beta-lactamase
enzymes
• Not active against MRSA
SIDE-EFFECT:
• Convulsions
• Seizures
• headache
Monobactam
 Aztreonam
EFFECTIVE AGAINST:
• Gram positive +Gram
negative+Anaerobic bacteria
CHARACTERISTICS:
• Broad Spectrum
• Intravenous
• Resistant to beta-lactamase
enzymes
• Not active against MRSA
SIDE-EFFECT:
• Diarrhoea
• Nausea
• Vomiting
 BETA-LACTAMASE INHIBITORS

• Resemble β-lactam antibiotic structure

• Bind to β-lactamase and protect the antibiotic from destruction
• Most successful when they bind the β-lactamase irreversibly
• Three important in medicine:
» Clavulanic Acid
» Sulbactam
» Tazobactam
Beta–lactam Resistance
 Resistance-The Global Battle.!!!

What is Resistance?

•Drug resistance refers to unresponsiveness of a microorganism

to an antimicrobial agent.

•Drug resistance are of two types:

---Natural Resistance
---Acquired Resistance
Natural Resistance:
•Some microbes have always been resistant to certain anti-microbial agent.
•They lack the metabolic process or the target side thai is affected by
particular drug.
E.g: Gram negative bacilli are normally unaffected by Penicillin G.
M. tuberculosis is insensitive to Tetracyclines.
•This type of resistance does not pose significant clinical problem.

Acquired Resistance:
•It is the development of resistance by an organism which was sensiive before
due to the use of antimicrobial agent over a period of time.
•This can happen with any microbe and is a major clinical problem.
However, the development of resistance is dependent on the microorganism
as well as the drug.
 MECHANISMS OF RESISTANCE

Porins
Altered penicillin binding proteins
b-lactamases
MECHANISMS FOR ACQUIRING
RESISTANCE

69
 CHALLENGES OF b-LACTAMASES
1940 : Introduction of penicillins
1940 : First description of b-lactamases published
1944 : Strains of staphylococcus aureus producing
b-lactamase
1960s : Clinical use of expanded spectrum penicillins
- such as ampicillin and carbenicillin
1970s : plasmid mediated b-lactamases assumed prominence in
enterobacteriaceae and gram-negative bacteria
1980-90 : Development of broad-spectrum cephalosporins, cephamycins,
monobactams and carbapenems
1990 : Increased resistance among gram-negative bacteria with inducible
chromosomally-mediated b lactamases
JAC (1993); suppl A: 1-8
Beta–lactamases
 Beta-Lactamase Enzyme
Functional
Classification

Group 1 Group 4
(Cephalosporinases*) (Penicillinases*)

Group 2 Group 3
(Penicillinases,
(Metalloenzymes*)
Cephalosporinases)

* Not inhibited by Clavulanic Acid

 Beta-Lactamase Enzyme

Molecular
Classification

Metallo
Serine Based
B-lactamases

Class A Class C Class D Class B

 Beta-Lactamase Enzyme

Molecular
Classification

Metallo
Serine Based
B-lactamases

Class A Class C Class D Class B

 Extended spectra Beta-Lactamase
(ESBL)
ESBLs are enzymes that mediate resistance to
extended-spectrum (third generation)
cephalosporins (e.g., ceftazidime, cefotaxime,
and ceftriaxone) and monobactams (e.g.,
aztreonam) but do not affect cephamycins
(e.g., cefoxitin and Cefotetan) or carbapenems
(e.g., meropenem or imipenem).
 WHY SHOULD WE DETECT THESE ENZYMES?

• The presence of an ESBL-producing organism in a clinical infection can

result in treatment failure if one of the above classes of drugs is used.
• ESBLs can be difficult to detect because they have different levels of
activity against various cephalosporins. Thus, the choice of which
antimicrobial agents to test is critical. For example, one enzyme may
actively hydrolyze ceftazidime, resulting in ceftazidime minimum
inhibitory concentrations (MICs) of 256 µg/ml, but have poor activity on
cefotaxime, producing MICs of only 4 µg/ml.
• If an ESBL is detected, all penicillin's, cephalosporins, and aztreonam
should be reported as resistant, even if in vitro test results indicate
susceptibility
 RISK FACTORS FOR ESBL INFECTION

• Length of hospital stay

• Severity of illness
• Time in the ICU
• Intubation and mechanical ventilation
• Urinary or arterial catheterization
• Previous exposure to antibiotics
 Metallo Beta-lactamase
• Resistant against broad spectrum of beta-lactam antibiotics
• These include the antibiotics of the carbapenem family.
• This class of β-lactamases is characterized by the ability to
hydrolyze carbapenems and by its resistance to the
commercially available β-lactamase inhibitors but susceptibility
to inhibition by metal ion chelators.
• The most common bacteria that make this enzyme are Gram
negative such as Escherichia coli and Klebsiella pneumoniae ,
Pseudomonas aeroginosa.
 BETA-LACTAMASE INHIBITORS

• Resemble β-lactam antibiotic structure

• Bind to β-lactamase and protect the antibiotic from destruction
• Most successful when they bind the β-lactamase irreversibly
• Three important in medicine:
» Clavulanic Acid
» Sulbactam
» Tazobactam