ANTIBACTERIALS I

Miss H Parkar (hafiza.parkar@up.ac.za)

What is an Antibiotic?
• An agent which destroys or inhibits microbial growth

• Originally referred to any agent with biological activity against living micro-
organisms including bacteria, fungi, protozoa
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Antimicrobials versus Antibiotics
• Antibiotic: low molecular substance produced by a microorganism
that at a low concentration inhibit or kill other microorganisms

• Antimicrobial: any substance of natural, semisynthetic or synthetic

origin that kills or inhibits the growth of microorganisms but causes
little or no damage to the host
Antimicrobials versus Antibiotics
• Antibiotics do not include antimicrobials which are:
• Synthetic (sulfonamides)
• Semisynthetic (amoxicillin)
• Plant (alkaloids) or animal derivatives (lysozyme)

All antibiotics are

antimicrobials but not all
antimicrobials are antibiotics
Antimicrobials versus Antibiotics
• Antimicrobials: all agents acting against all microorganisms
• Bacteria, viruses, fungi and protozoa
• Classification of antimicrobials based on
• Chemical structure
• Mechanism of action
• Site of action
• Activity against microorganisms
• Antibacterials
• Largest and most widely known class of antimicrobials
What is Resistance?
• Bacteria are considered resistant to an antibiotic if the maximal level of that
antibiotic that can be tolerated by the host does not halt their growth
• Some organisms are inherently resistant to an antibiotic
• Microbial species that are normally responsive to a particular drug may
develop more virulent or resistant strains
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• Some strains become resistant to more than one antibiotic
Resistance

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Resistance
“The world is heading towards a post-antibiotic era, in which
common infections and minor injuries, which have been
treatable for decades, can once again kill” - WHO

Drug resistant tuberculosis now affects 630,000 people

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Ten countries have reported cases of gonorrhea that don't respond to

any antibiotic

Drug effectiveness is declining for serious diseases like

malaria, HIV and the flu
Bacteria
• Prokaryotes (single-celled or non-cellular organisms)
• Reproduce by fission (splitting into two or more parts)
• Lack a membrane-bound nucleus, mitochondria and other membrane-bound
organelles
• Phyla:
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1. Gram (+): no outer membrane with thick peptidoglycan layer
2. Gram (-): outer membrane
3. Unknown/ungrouped
Gram-positive Bacteria
• Simple structure, 15-50 nm thick
• 50% peptidoglycan
• 40-45% acidic polymer (highly polar, negatively charged)
• 5-10% proteins and polysaccharides
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Gram-negative Bacteria
• Complex structure
• Periplasmic space
• Peptidoglycan layer (2 nm thick)
• Outer membrane: lipid bilayer
• Proteins lipoproteins linked to peptidoglycan and porins
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• Complex polysaccharides
Gram staining
• Differentiates bacterial species into gram-positive and gram-negative
• Detection of peptidoglycan in cell walls present in large amounts in the cell
wall of Gram-positive bacteria
• Gram-negative cells also contain peptidoglycan, but a very small layer of it
that is dissolved when the alcohol is added and therefore loses its colour
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• Gram-positive bacteria retain crystal violet dye (stained violet)
• Gram-negative bacteria do not, counterstain is added (safranin or fuchsine)
which stains Gram-negative bacteria a pink colour
Gram staining Procedure
https://youtu.be/2gTaZUSvn58

• Primary stain (crystal violet) applied to a heat-fixed smear of a bacterial

culture
• Heat fixation kills some bacteria but is mostly used to affix the bacteria to the
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slide so that they don't rinse out during the staining procedure
• Iodide is the added which binds to crystal violet and traps it in the cell
• Rapid decolorization with ethanol or acetone
• Counterstaining with safranin or Carbol fuchsin (anaerobic bacteria)
Bacterial morphology

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Bacterial Growth Curve

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Bacterial Growth Curve
1. Lag phase:
• Bacterial cells adapt to environment and LITTLE GROWTH
OCCURS
2. Exponential growth phase also known as log phase:
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• Bacterial cells flourish and multiply- EXPONENTIAL GROWTH
3. Stationary phase:
• Nutrient sources become scarce and toxic metabolites can
accumulate- CELL GROWTH = CELL DEATH
4. Death phase:
• Growth decreases as cell death and hibernation increases-
DECLINE IN CELL NUMBERS
Factors Affecting Bacterial Growth
1. Solute and water activity
• Changes in osmotic concentration of the surroundings can affect growth
2. pH
• Each species has a definite pH growth range
3. Temperature
• Temperature affects sensitivity of enzyme-catalyzed reactions
4. Oxygen level
• Aerobe- grow in the presence of atmospheric O2
• Anaerobe- grow in absence of atmospheric O2
5. Pressure
• Bacteria found in deep sea are subjected to high pressure
6. Radiation
• Many forms of electromagnetic radiation are very harmful to
microorganisms
Medically Important Microorganisms
1. Gram (+) and (-) cocci
• Spherical, ovoid shaped
2. Gram (+) and (-) bacilli
• Rod-shaped
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3. Spirochaetes
• Double membraned long, helically coiled
4. Mycoplasma
• Lack a cell wall around cell membrane
5. Anaerobic organisms
• Obligate, aerotolerant, facultative
Medically Important Microorganisms
Micro-organism
Gram-positive cocci
Gram-negative cocci
Gram-positive bacilli
Gram-negative bacilli
Spirochaetes (gram-negative)
Main illness or disease state
Septic infections (bacteraemia, toxic shock),
endocarditis, pneumonia
Sinusitis, gonorrhoea, meningitis
Tetanus, gangrene, diphtheria
Urinary tract infections, dysentery, typhoid, cholera,
pneumonia, peptic ulcer associated helicobacter,
influenza infections of the ear, sinus and respiratory
tract, meningitis, syphilis, Lyme disease, tick-bite fever
Lyme disease, relapsing fever, syphilis, yaws

Clinically important microorganisms in decreasing frequency are:

1. Gram-negative bacilli
2. Gram-positive cocci
3. Gram-positive spore-forming and non-spore-forming bacilli
4. Gram-negative cocci
Diagnosing Microbial Diseases
1. Direct or indirect identification
• Microscopy in combination with biochemical staining
2. Microbial culture
• Streak plate method
3. Biochemical tests
• Metabolic and enzymatic products
4. Molecular diagnostics
• PCR allows for identification and testing for specific
nucleic acids
Terminology
• Minimal Inhibitory Concentration (MIC)
• Minimum concentration needed to inhibit growth of organism
• Lower MIC, more effective
• Good indicator of potency
• Minimal Bacteriocidal Concentration (MBC)
• Minimum concentration needed to kill the organism
• Lower MBC, more effective
• Tolerance
• Reduced MIC and increased MBC
• Defined as an MBC/MIC ratio
Terminology
• Selective toxicity
• Ability to inhibit growth or kill pathogen without harming host cell
• Takes advantage of biochemical differences
• Cidal
• Antimicrobials that kill
• Static
• Antimicrobials that inhibit
growth and replication
Selection of Antimicrobial Agents
1. Identification of infecting organism
2. Empirical therapy prior to identification
3. Antimicrobial susceptibility testing
• Narrow, broad or extended spectrum
• Mono- or combination therapy
4. Severity of infection
5. Drug-related factors
6. Site and type of infection
7. Patient factors
8. Cost of therapy
Selection of Antimicrobial Agents
• Site of infection
• Lipid solubility of drug
• Molecular weight of drug
• Protein binding of drug
• Patient factors
• Pregnancy and lactation
• Immune system
• Renal / hepatic dysfunction
• Poor perfusion
• Age
Selection of Antimicrobial Agents
• Types of infection
• Localized or extensive
• Mild or severe
• Superficial or deep
• Acute, sub-acute or chronic
• Extracellular or intracellular
• Severity of infection
• Infection with multiple organisms
• Sensitivity of organism
• Source of infection: community versus hospital
acquired
Chemotherapeutic spectra
• Narrow-spectrum antibacterial
• Activity against single or limited group of
microorganisms
• Isoniazid
• Broad-spectrum antibacterial
• Activity against gram (+) and some gram (-)
microorganisms
• Tetracycline and chloramphenicol
• Can drastically alter normal bacterial flora
• Extended-spectrum antibacterial
• Chemical modifications enhance activity
• Carbenicillin
Types of Antibacterial Therapy
• Definitive or directed therapy
• Confirmed bacterial infections
• Narrow spectrum, lower toxicity, cheap and easy-to-
administer
• Empirical therapy
• Restricted to critical cases and influenced by site of
infection
• Time is inadequate for identification and isolation
• Septicaemia, immunocompromised, severe systemic
infection, neutrophilic leukocytosis, raised ESR
• Drug that covers most probable infective agent
Types of Antibacterial Therapy
• Prophylaxis
• Medical: tuberculosis, rheumatism, endocarditis
• Surgical: invasive medical procedures
• No single prophylaxis for all possible bacterial infections
• Narrow spectrum, highly specific drugs
Rational dosing
• Concentration-dependent killing
• High peak plasma levels: rapid killing of pathogen
• Aminoglycosides, fluroquinolones, carbapenems
• Time-dependent killing
• Beta-lactams, glycopeptides, macrolides
• Post-antibiotic effect (PAE)
• Persistent suppression of microbial growth once antibiotic levels
fall below MIC
• Time defined as time taken to achieve log-phase growth
• Long PAE: one dose per day
PK/PD Approaches
• Pharmacokinetics
• Time course of antimicrobial concentrations
• Pharmacodynamics
• Relationship between concentration and
antimicrobial effect
• MIC: indicator of potency but not time-course
of activity
PK/PD Approaches
• Key pharmacokinetic parameters
• Quantify serum level time course but not killing activity
• Peak serum level: Cmax
• Trough level: Cmin
• Area under serum concentration
curve (AUC)
PK/PD Approaches

PK/PD parameters
quantifying antimicrobial
activity:
• Peak/MIC ratio
• T>MIC (time above MIC)
• 24 hours-AUC/MIC ratio
Antibacterial Patterns
1. Type I
2. Type II
3. Type III

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Type I Antibacterials
• Concentration-dependent killing
• Prolonged persistent effects
• Ideal dosing regimen
• Maximize concentration
• Higher concentration: more extensive and faster of killing
• Predictors of antibiotic response
• 24h-AUC/MIC ratio
• Peak/MIC ratio efficacy
• Aminoglycosides, fluoroquinolones
Type II Antibacterials
• Time-dependent killing and minimal persistent effects
• Demonstrate opposite properties to type I antibiotics
• Ideal dosing regimen
• Maximizes the duration of exposure
• Predictors of antibiotic response
• T>MIC (time above MIC)
• Beta-lactams, erythromycin
• Maximum killing
• T>MIC is at least 70% of dosing interval
Type III Antibacterials
• Time-dependent killing
• Moderate to prolonged persistent effects
• Mixed properties
• Ideal dosing regimen
• Maximizes the amount of drug
• Predictors of antibiotic response
• 24h-AUC/MIC ratio
• Azithromycin, vancomycin
Antibacterials Patterns *
Goal of
Pattern of Activity Antibacterials PK/PD Parameter
Therapy
Type I
Aminoglycosides
Concentration-
Daptomycin Maximize 24h-AUC/MIC
dependent killing and
Fluoroquinolones concentrations Peak/MIC
prolonged persistent
Ketolides
effects
Type II Carbapenems
Maximize
Time-dependent killing Cephalosporins
duration of T>MIC
and minimal persistent Erythromycin
exposure
effects Penicillins
Type III
Azithromycin
Time-dependent killing Maximize
Clindamycin
and amount of 24h-AUC/MIC
Tetracyclines
moderate to prolonged drug
Vancomycin
persistent effects
Discussion board question
Antibiotic resistance is one of the greatest problems this
generation faces. Consider the statement below:

“The world is heading towards a post-antibiotic era, in which

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common infections and minor injuries, which have been
treatable for decades, can once again kill” - WHO

1. What would consequences be if antibiotics no longer worked?

2. Which types of treatment or procedures would pose a great risk
for the patient in terms of infection?