001 - General Principles of Antimicrobial Therapy

“Corso di Laurea in Medicina e Chirurgia”
Insegnamento di Farmacologia 1 – IV anno – Programma di Chemioterapia AA 2019-2020

Luca.Pani@unimore.it @Luca__Pani
1. General Principles of Antimicrobial Therapy

2. Chemotherapy of Malaria
3. Chemotherapy of Protozoal Infections: Amebiasis, Giardiasis, Trichomoniasis, Trypanosomiasis, Leishmaniasis, and
Other Protozoal Infections
4. Chemotherapy of Helminth Infections
5. Sulfonamides, Trimethoprim-Sulfamethoxazole, Quinolones, and Agents for Urinary Tract Infections
6. Penicillins, Cephalosporins, and Other β-Lactam Antibiotics
7. Aminoglycosides
8. Protein Synthesis Inhibitors and Miscellaneous Antibacterial Agents
9. Chemotherapy of Tuberculosis, Mycobacterium avium Complex Disease, and Leprosy
10. Antifungal Agents
11. Antiviral Agents (Nonretroviral)
12. Treatment of Viral Hepatitis (HBV/HCV)
13. Antiretroviral Agents and Treatment of HIV Infection
“Corso di Laurea in Medicina e Chirurgia”
Insegnamento di Farmacologia 1 – IV anno – Lecture 001
AA 2019-2020
General Principles of
Antimicrobial Therapy
Luca Pani, MD
Professor of Pharmacology and Clinical Pharmacology - University of Modena and Reggio Emilia, Modena, Italy
Professor of Clinical Psychiatry – Univ. of Miami – Miami, USA
Former CHMP, SAWP Member, European Medicine Agency (EMA), London – UK
Former Director General, Italian Medicines Agency (AIFA), Rome – IT
Luca.Pani@unimore.it @Luca__Pani
Disclaimer and Disclosure
The opinions expressed in this presentation are my personal views and may not be understood or quoted as
being made on behalf of or reflecting the position of any of the Institutions or Companies for which I have
worked or I collaborate with.
The mention of commercial products, their sources, or their use in connection with material reported herein is
not to be constructed as either an actual or implied endorsement of such products to any Public Department
or Health and/or Payer Services.
Apart from my Academic roles, I am the Chief Scientific Officer of EDRA-LSWR Publishing Company and of
Inpeco SA Total Lab Automation Company. I do not bear any direct or indirect financial interest in
products quoted in this talk.
These slides are both original or have been modified from presentations/videos from General Principles of
Antimicrobial Therapy, Brunton LL, Hilal-Dandan R, Knollmann BC. In Goodman & Gilman's: The
Pharmacological Basis of Therapeutics, XIII Ed.; 2017, Copyright ©2019 McGraw-Hill Education. All rights
reserved (Edizione Italiana, Zanichelli Editore, 2019)
This presentation is updated to September 24th , 2019.

Abbreviations
ABC: ATP binding cassette EC: effective concentration
AUC: area under the Cp-time curve ELF: epithelial lining fluid
CCR5: chemokine receptor type 5 Emax: maximal effect
CD4: T-helper cells H: the slope of the curve or Hill factor
CFU: colony-forming unit HIV: human immunodeficiency virus
CMV: cytomegalovirus IC: inhibitory concentration
CNS: central nervous system MALDI-TOF MS: matrix-assisted laser desorption/ionization
Cp: plasma concentration time-of-flight mass spectrometry
CPmax: peak concentration mdr1: multidrug resistance gene
CSF: cerebrospinal fluid MEC: minimum effective concentration
DHFR: dihydrofolate reductase MIC: minimum inhibitory concentration
DHPS: dihydropteroate synthase PAE: post antibiotic effect
E: effect PCR: polymerase chain reaction
PK/PD: pharmacokinetics-pharmacodynamics
rpoB: RNA polymerase
Before we start, please remember…
Sir Charles Darwin

(1809-1882)
Problem is we cannot “picture” evolution.
Can you picture a 3BY time scale?
• If every year is a letter then you could write 1000 giant books of 1000
pages each
• These books would build an 80 mt. tower

• The divergence between non-human and human primates starts at
the end of page number 332 of the book number 999
• We and Aristotle are on the same last page
• (Archean) Bacteria are the first letter of the first line of the first book.
On the tree of life, humans are closer to corn, a green plant,
than two common bacteria are to each other
“Humanity is just a speck in
the massively bacterial world.
We need to get used to that idea.”
Summary of the present lecture
Antimicrobial Therapy: Classes and Actions
The germ theory of disease, based on the work
of Louis Pasteur and Robert Koch, was a
revolution in the human understanding of
nature that linked specific microorganisms to
specific diseases. The germ theory developed
considerably in the 20th century, with
identification and characterization of many
microbial pathogens and their pathogenic
mechanisms and the introduction of
antimicrobial drugs. With the use of these drugs
came issues of appropriate regimens, drug
resistance, drug interactions, and toxicity.
Microorganisms of medical importance fall into
four categories: bacteria, viruses, fungi, and
parasites. The first broad classification of
antibiotics follows this classification closely, so
that we have antibacterial, antiviral, antifungal,
and antiparasitic agents. However, there are
many antibiotics that work against more than
one category of microbes, especially those that
target evolutionarily conserved pathways.
Within each of these major categories, drugs are
further categorized by their biochemical
properties.
Antimicrobial molecules should be viewed as
ligands whose receptors are microbial proteins.
The term pharmacophore, defines that active
chemical moiety of the drug that binds to the
microbial receptor. Historically, pharmacophores
were established by Lemont Kier, who first
mentions the concept in 1967. The development
of the concept is often erroneously accredited to
Paul Ehrlich. The microbial proteins targeted by
the antibiotic are essential components of
biochemical reactions in the microbes, and
interference with these physiological pathways
kills the microorganisms.
The biochemical processes commonly

inhibited include cell wall synthesis in
bacteria and fungi, cell membrane
synthesis, synthesis of 30S and 50S
ribosomal subunits, nucleic acid
metabolism, function of topoisomerases,
viral proteases, viral integrases, viral
envelope entry/fusion proteins, folate
synthesis in parasites, and parasitic
chemical detoxification processes.
Recently, antisense antibiotics have been

developed; these work by inhibiting gene
expression in bacteria in a sequence-specific
manner.
Furthermore, interferon-based products

work by inducing specific antiviral activities
of the infected human cells.
Kane et al., 2016, Cell Host & Microbe 20, 392–405

Classification of an antibiotic is based on the following:
• class and spectrum of microorganisms it kills

• biochemical pathway it interferes with
• chemical structure of its pharmacophore
Because antimicrobial agents are ligands that bind to their targets to
produce effects, the relationship between drug concentration and effect on
a population of organisms is modeled using the standard Hill-type curve for
receptor and agonist, characterized by three parameters:
• IC50 (also termed EC50), the inhibitory concentration that is 50% effective,
a measure of the antimicrobial agent’s potency
• Emax, a measure of the maximal effect
• H, the slope of the curve, or Hill factor
Inhibitory sigmoid Emax curve.
E = Econ – Emax x (IC)H/[(IC)H+ (IC50)H]
Where:
• IC50 the inhibitory concentration that is
50% effective, a measure of the
antimicrobial agent’s potency
• H, the slope of the curve, or Hill factor
and
• Econ is control bacterial population
without treatment
Changes in sigmoid Emax model with increases in drug
resistance.
An increase in resistance may show changes in IC50: In A, the IC50 increases from 70 (orange line)
to 100 (green line) to 140 (blue line). An increase in resistance may also show a decrease in Emax:
In B, efficacy decreases from full response (orange line) to 70% (green line).
Effect of different dose schedules on shape of the
concentration-time curve.
The same total dose of a drug was administered as a single dose (panel A) and in three equal portions every 8 h
(panel B). The total AUC for the fractionated dose in B is determined by adding AUC0–8h, AUC8–16h, and AUC16–
24h, which totals to the same AUC0–24h in A. The time that the drug concentration exceeds MIC in B is also
determined by adding T1 > MIC, T2 > MIC, and T3 > MIC, which results in a fraction greater than that for A.
Penetration of Antimicrobial Agents Into Anatomic
Compartments
In many infections, the pathogen causes
disease not in the whole body, but in
specific organs. Within an infected organ
only specific pathological compartments
may be infected. Antibiotics are often
administered orally or parenterally, far
away from these sites of infection.
Therefore, in choosing an antimicrobial
agent for therapy, a crucial consideration is
whether the drug can penetrate to the site
of infection.
Penetration of Antimicrobial Agents Into Anatomic
Compartments
For example, the antibiotic levofloxacin achieves
a skin tissue/peak plasma concentration CPmax
ratio of 1.4, ELF/(Cp)ratio of 2.8, and urine/(Cp)
ratio of 67. The two most important factors in
predicting successful clinical and microbiological
outcomes using levofloxacin in the patients are
the site of infection and achieving a CPmax level of
12 times the MIC (CPmax/MIC ≥12). The failure rate
of therapy is 0% in patients with urinary tract
infections, 3% in patients with pulmonary
infections, and 16% in patients with skin and so
tissue infections. Clearly, the poorer the
penetration into the anatomical compartment,
the higher the likelihood of failure.
(Chow et al., 2002; Conte et al., 2006; Wagenlehner et al., 2006; Preston et al., 1998)
The Penetration of Antimicrobial Agents Into Anatomic
Compartments is a function of three major factors:
a) The physical barriers that the molecule must traverse
b) The chemical properties of the drug
c) The presence of multidrug transporters

a) The physical barriers that the molecule must traverse
The physical barriers are usually due to layers of epithelial and endothelial cells and the type of
junctions formed between these cells. Penetration across this physical barrier generally
correlates the hydrophilicity or hydrophobicity of the drug
b) The chemical properties of the drug
Hydrophobic molecules concentrate
in the bilipid cell membrane bilayer,
whereas hydrophilic molecules tend
to concentrate in the blood, the
cytosol, and other aqueous
compartments. Thus, the greater its
lipophilicity, the greater the likelihood
that an antimicrobial agent will cross
physical barriers erected by layers of
cells. Conversely, the more charged
Influence of pH on the distribution of a weak acid (pKa = 4.4)
a molecule is, and the larger it is, the
between plasma and gastric juice separated by a lipid barrier. A
poorer its penetration across weak acid dissociates to different extents in plasma (pH 7.4) and
membranes and other physical gastric acid (pH 1.4): The higher pH facilitates dissociation; the lower
barriers. pH reduces dissociation. The uncharged form, HA, equilibrates
across the membrane. Blue numbers in brackets show relative
equilibrium concentrations of HA and A−.
c) The presence of multidrug transporters
Another barrier is due to membrane
transporters, which actively export drugs
from the cellular or tissue compartment back
into the blood. A well-known example is the
P-glycoprotein. P-glycoprotein exports
structurally unrelated amphiphilic and
lipophilic molecules of 3–4 kDa, their
effective penetration. Examples of
antimicrobial agents that are P-glycoprotein
substrates include HIV protease inhibitors,
the antiparasitic agent ivermectin, the
antibacterial agent telithromycin, and the
antifungal agent itraconazole
Antimicrobial agents penetration and different anatomical
compartments (examples):
1. CNS
2. Eye
3. Pericardium
4. Biofilms
5. Pharmacokinetic Compartments
1. CNS
The CNS is guarded by the blood-brain barrier (BBB).
The movement of antibiotics across the blood-brain
barrier is restricted by tight junctions. Antimicrobial
agents that are polar at physiological pH generally
penetrate poorly; some, such as penicillin G, are actively
transported out of the CSF and achieve CSF
concentrations of only 0.5%–5% of the Cp. However, the
integrity of the BBB is diminished during active bacterial
infection; tight junctions in cerebral capillaries open,
leading to a marked increase in the penetration of even
polar drugs. As the infection is eradicated and the
inflammatory reaction subsides, penetration diminishes
to normal. Because this may occur while viable
microorganisms persist in the CSF, drug dosage should
not be reduced as the patient improves.
(Daneman and Prat, 2015).
2. EYE
Drug penetration into the eye is
especially pertinent in the
treatment of endophthalmitis and
infections of the retina. There is
generally poor penetration of drug
from plasma to this compartment,
so that the standard therapy is
direct instillation of antibiotics into
the ocular cavity. In patients with
pulmonary infections such as
pneumonia, drugs must penetrate
into the ELF, where the pathogens
are found
(Kiem and Schentag, 2008)
3. PERICARDIUM
Drug penetration into the pericardium is governed
by physical barriers and also likely by some form of
active transport. In patients treated for tuberculous
pericarditis with the regimen of isoniazid, rifampin,
pyrazinamide, and ethambutol, simultaneous blood
and pericardial fluid concentrations were measured
over 24 h. Rifampin concentrations in pericardial
fluid were only 20% those in plasma due to poor
penetration as well as active clearance, while
ethambutol CPmax was 55% due to poor penetration.
On the other hand, isoniazid and pyrazinamide
concentrations in pericardial fluid and blood were
equivalent. So, DO NOT assume that different drugs
penetrate equally to the compartment of concern.
(Shenje et al., 2015)
4. BIOFILMS
Compartments requiring special drug
penetration are endocardial vegetations and
the biofilm formed by bacteria and fungi on
prosthetic devices such as artificial heart
valves, long-dwelling intravascular catheters,
artificial hips, and devices for internal fixation
of bone fractures. Bacterial and fungal
biofilms are colonies of slowly growing cells
enclosed within an exopolymer matrix. The
exopolysaccharide is negatively charged and
can bind positively charged antibiotics and
restrict their access to the intended target. To
be effective against infections in these
compartments, antibiotics have to be able to
penetrate the biofilm and endothelial
barriers.
David Lebeaux et al. Microbiol. Mol. Biol. Rev. 2014; Sun et al, 2013
5. PHARMACOKINETICS COMPARTMENTS (important!)
Once an antibiotic has penetrated to the site of infection, it may be subjected to processes of elimination and
distribution that differ from those in the blood. Sites where the concentration-time profiles differ from each other
are considered separate pharmacokinetic compartments; thus, the human body is viewed as multicompartmental.
The concentration of antibiotic within each compartment is assumed to be homogeneous. If two compartments
have similar concentration profiles, then they may be considered a single compartment.
Allow me a short digression on PharmacoKinetics (PK) here
Remember that these are the three essential PK aspects of drug metabolism:
• First-order kinetics. For most drugs in their therapeutic concentration ranges, the amount
of drug metabolized per unit time is proportional to the plasma concentration of the drug
(Cp) and the fraction of drug removed by metabolism is constant (i.e., first-order kinetics).
• Zero-order kinetics. For some drugs, such as ethanol and phenytoin, metabolic capacity is
saturated at the concentrations usually employed, and drug metabolism becomes zero
order; that is, a constant amount of drug is metabolized per unit time. Zero-order kinetics
can also occur at high (toxic) concentrations as drug-metabolizing capacity becomes
saturated.
• Inducible biotransforming enzymes. The major drug-metabolizing systems are inducible,

broad-spectrum enzymes with some predictable genetic variations. Drugs that are
substrates in common for a metabolizing enzyme may interfere with each other’s
metabolism, or a drug may induce or enhance metabolism of itself or other drugs..
Antibiotic concentrations can be analyzed
using any number of such compartments, with
the best number of compartments chosen
based on the least number of compartments
that can adequately explain the findings. The
model is also defined as open or not open; an
open model is one in which the drug is
eliminated out of the body from the
compartment (e.g., kidneys). The kinetic order
of the process must also be specified. A first-
order process is directly correlated to
concentration of drug D, or [D]1, as opposed
to zero order, which is independent of [D] and
reflects a process that is saturated at ambient
levels of D.
Consider a patient with pneumonia, with the
pathogen in the lung Epithelial lining fluid (ELF). The
patient ingests an antibiotic that is absorbed via the
GI tract (g) into blood or the central compartment
(compartment 1) as a first-order input. In this
process, the transfer constant from the GI tract to
central compartment is termed the absorption
constant and is designated ka. The antibiotic in the
central compartment is then delivered to the lungs,
where it penetrates into the ELF (compartment 2).
However, it also penetrates into other tissues of the
body peripheral to the site of infection, termed the
peripheral compartment (compartment 3).
Kiem S., and Schentag JJ, Antimicrob. Agents Chemother. 2008

Diagrammatic depiction of a multicompartment model.
Ka, absorption constant; Vc, central compartment volume; VL, volume of lung
compartment; Vp, peripheral compartment volume.
Thus, we have four compartments (including G, a specific compartment, the GI tract, from the set of initial
absorption compartments in the figure, each with its own concentration-time profile. The penetration of drug
from compartment 1 to 2 is based on the penetration factors discussed previously and is defined by the transfer
constant k12. However, the drug also redistributes from compartment 2 back to 1, defined by transfer constant
k21. A similar process between the blood and peripheral tissues leads to transfer constants k13 and k31. The drug
may also be lost from the body (i.e., open system) via the lungs and other peripheral tissues (e.g., kidneys or
Impact of susceptibility testing on success of antimicrobial
agents
DO NOT GIVE ANTIBIOTICS IF YOU DON’T KNOW AGAINST WHAT!
The microbiology laboratory plays a
central role in the decision to choose
a particular antimicrobial agent over
others. First, identification and
isolation of the culprit organism takes
place when the patients’ specimens
are sent to the microbiology
laboratory. Once the microbial
species causing the disease has been
identified, a rational choice of the
class of antibiotics likely to work in
the patient can be made. The
microbiology laboratory then plays a
second role, which is to perform
susceptibility testing.
agents
DO NOT GIVE ANTIBIOTICS IF YOU DON’T KNOW AGAINST WHAT!
Millions of individuals across the globe become
infected by many different isolates of the same
species of pathogen. Evolutionary processes cause
each isolate to be slightly different from the next,
so that each may have a unique susceptibility to
antimicrobial agents. As the microorganisms divide
within the patient, they may undergo further
evolution between the time of infection and the
time of diagnosis. Therefore, one observes a
distribution of concentrations of antimicrobial
agents that can kill the pathogens. Often, this
distribution is Gaussian, with a skew that depends
on where the patient lives. Such factors will affect
the shape of the inhibitory sigmoid Emax model
curve.
agents
With changes in susceptibility, the sigmoid Emax
curve shifts in one of two basic ways. The first is a
shift to the right, an increase in IC50, meaning that
much higher concentrations of antimicrobials than
before are now needed to show specific effect.
Susceptibility tests for bacteria, fungi, parasites,
and viruses have been developed to determine
whether these shifts have occurred at a sufficient
magnitude to warrant higher doses of drug to
achieve particular effect. The change in IC50 may
become so large that it is not possible to overcome
the concentration deficit by increasing the
antimicrobial dose without causing toxicity to the
patient. At that stage, the organism is now
“resistant” to the particular antibiotic.
agents
A second possible change in the curve is
decrease in Emax, such that increasing the dose
of the antimicrobial agent beyond a certain
point will achieve no further effect; that is,
changes in the microbe are such that eradication
of the microbe by the particular drug can never
be achieved. This occurs because the available
target proteins have been reduced or the
microbe has developed an alternative pathway
to overcome the biochemical inhibition. For
example, this type of resistance is the one for
maraviroc, an allosteric, noncompetitive
antagonist that binds to the CCR5 receptor of
patient’s CD4 cells to deny HIV entry into the
cell.
Specific susceptibility testing: Bacteria
For bacteria, dilution tests employ antibiotics in serially
diluted concentrations on solid agar or in broth medium that
contains a culture of the test microorganism. The lowest
concentration of the agent that prevents visible growth after
18–24 h of incubation is known as the minimum inhibitory
concentration (MIC). Recently, nucleic acid amplification–
based reactions of specific bacterial genes have been used
for rapid diagnosis of drug resistance. The genes targeted
are those encoding known drug resistance proteins or
processes. For example, rifampin resistance in
Mycobacterium tuberculosis (it takes 2 to 3 weeks to grow
and then another 2 weeks to test). tests. Small PCR reactors
at points of care can identify mutations, and provide a result
in less than 2 h. In other bacteria, MALDI-TOF MS is being
used for identification of resistance to drugs such as
vancomycin in Staphylococcus aureus and is being extended
to many other compounds and bacterial species.
Specific susceptibility testing: Fungi
For fungi that are yeasts (i.e., Candida),
susceptibility testing methods are similar to
those used for bacteria. However, the
definitions of MIC differ based on drug and
the type of yeast, so there are cutoff points
of 50% decrease in turbidity compared to
controls at 24 h, 80% at 48 h, or total
clearance of the turbidity. Susceptibility tests
and MICs for triazoles, echinocandin
antifungals, amphotericin B–based
compounds, molds especially for Aspergillus
species are now available. The minimum
effective concentration (MEC) for
echinocandins is the lowest drug
concentration at which short, stubby, and
highly branched hyphae are observed on
microscopic examination.
Specific susceptibility testing: Viruses
In HIV phenotypic assays, the patient’s HIV-
RNA is extracted from plasma, and genes for
targets of antiretroviral drugs such as reverse
transcriptase and protease are amplified. The
genes are then inserted into a standard HIV
vector that lacks an alogous gene sequences
to produce a recombinant virus, which is
coincubated with a drug of interest in a
mammalian cell viability assay. Growth is
compared to a standardized wild-type control
virus. Genotypic tests are now a standard
part of HIV care in many parts of the world.
The simplest tests measure presence of
mutations associated with loss of
susceptibility to a drug, that is, that the
organism is “resistant” to the drug and the
drug should not be used to treat that patient.
(Hanna and D’Aquila, 2001; Petropoulos et al., 2000).
Specific susceptibility testing: Parasites
Susceptibility testing for parasites, especially
those that cause malaria, has been
performed in the laboratory. The tests are
similar to the broth tests for bacteria, fungi,
and viruses. Plasmodium species in the
patient’s blood are cultured ex vivo in the
presence of different dilutions of antimalarial
drug. A sigmoid Emax curve for effect versus
drug concentration is used to identify IC50 and
Emax. These susceptibility tests are usually
field tests at sentinel sites that are used to
determine if there is drug resistance in a
particular area. In general, susceptibility tests
for parasitic infections are not standardized.
These tests are primarily used in the research
setting and not for individualization of
therapy.
Abebe Genetu Bayih et al. Clin. Microbiol. Rev. 2017
Pharmacological basis for selection and dosing schedules
Susceptibility testing in the lab is central but
not enough. In tests, the drug concentration is
constant; in patients is dynamic and changing.
Antibiotics are prescribed at a certain
schedule (e.g., three times a day) so that there
is a periodicity in the fluctuations of drug at
the site of infection, and the microbe is
exposed to a particular shape of the
concentration-time curve. Harry Eagle
performed studies on penicillin and
discovered that the shape of the
concentration-time profile was an important
determinant of the efficacy of the antibiotic.
This important observation was forgotten until
William Craig and colleagues rediscovered it
and performed systematic studies on several
classes of antibiotics, initiating the era of
antimicrobial PK/PD.
PAE = Post-Antibiotic Effect
Principal PK-PD characteristics of antimicrobial drugs
Left: Time-dependent antibiotics (beta-lactams, including penicillins and penems, glycopeptides, linezolid, macrolides, etc.).
The time that the concentration of a drug remains above the MIC (T > MIC) is the PK-PD index correlating with efficacy. The
post-antibiotic effect (PAE) can be absent (macrolides), minimal (betalactams, including penicillins and penems), or
moderate (glycopeptides, linezolid). Right: Concentration-dependent antibiotics (aminoglycosides, fluoroquinolones). The
peak concentration/minimum inhibitory concentration (Cmax/MIC) ratio and/or the area under the concentration-time
curve at 24 h/MIC (AUC0-24/MIC) ratio are the best PK-PD modeling and simulation correlating with efficacy. Moreover,
there is a prolonged PAE with the concentration-dependent antibiotics.
The three precepts of antimicrobial therapy
I. Apply knowledge of the susceptibility (either MIC or IC90) of the
organism to the antimicrobial agent and index drug exposure to
MIC.
II. Use the optimal dose of the antibiotic for the patient, that is, the
dose that achieves IC80 to IC90 exposures at the site of infection.
III. Use a dosing schedule that maximizes the antimicrobial effect;
recognize that optimal microbial kill by the antibiotic may be best
achieved by maximizing certain shapes of the concentration-time
curve.
I. Apply knowledge of the susceptibility (either MIC or IC90) of the
organism to the antimicrobial agent and index drug exposure to
MIC.
a. As an example, the pyrazinamide MIC is an important determinant of M.
tuberculosis response and microbial measures of cure. In fact, microbial
response is driven by the ratio of the AUC to the MIC.
b. Similarly, in the treatment of candidemia, the rate of response is driven by
the ratio dose/MIC. This is not a surprise because the IC50 shifts to the right
with decrease in susceptibility.
(Chigutsa et al., 2015; Rodríquez-Tudela et al., 2007)

II. Use the optimal dose of the antibiotic for the patient, that is, the
dose that achieves IC80 to IC90 exposures at the site of infection.
a. Dose by itself is a poor measure of drug exposure. Rather, actual drug
concentration achieved at the site of infection is the important measure. The
shape of the relationship between non–protein-bound antibiotic
concentration (exposure) versus microbial kill is the inhibitory
sigmoid Emax curve. Maximal kill is actually on an asymptote, so that non–
protein-bound antimicrobial exposures associated with 80%–90% of Emax are
termed optimal concentrations.
b. This exposure can often be easily identified in preclinical models and directly
applied to patient populations, provided interspecies differences in protein
binding and pharmacokinetic variability are taken into account.
III. Use a dosing schedule that maximizes the antimicrobial effect;
recognize that optimal microbial kill by the antibiotic may be best
achieved by maximizing certain shapes of the concentration-time
curve.
A. As an example, consider an antibiotic with a serum t1/2 of 3 h that is being used to
treat a bloodstream infection by a pathogen with an MIC of 0.5 mg/L; the
antibiotic is administered with a dosing interval of 24 h (that is, a once-daily
schedule). The next figure depicts the concentration-time curve of the antibiotic,
with definitions of CPmax, AUC, and the fraction of the dosing interval for which the
drug concentration remains above the MIC (T > MIC), as shown. The AUC is a
measure of the total concentration of drug and is calculated by taking an integral
between two time points, 0–24 h (AUC0–24) in this case.
B. Now, if one were to change the dosing schedule of the same
antibiotic amount by splitting it into three equal doses
administered at 0, 8, and 16 h, the shape of the concentration-
time curve changes to that shown in panel B. Because the same
cumulative dose has been given for the dosing interval of 24 h,
the AUC0–24 will be similar whether it was given once a day or
three times a day. For the same pathogen, therefore, the change
in dose schedule does not change the AUC0–24/MIC. However,
the Cpmax will decrease by a third when the total dose is split into
thirds and administered more frequently. Thus, when a dose is
fractionated and administered more frequently, the CPmax/MIC
ratio decreases. In contrast, the time that the drug concentration
persists above MIC (T > MIC) will increase with the more frequent
dosing schedule, despite the same cumulative dose being
administered.
Q: Which of the three indices (AUC/MIC, CPmax/MIC, or T > MIC) is the most
important to the outcome being assessed (i.e., microbial kill)?
A: A common approach to the answer is to determine which of these patterns best approximates a
perfect inhibitory sigmoid Emax curve (based on various statistical assessments of goodness of fit) in
the Equation here E=E –E x (IC)H/[(IC)H+ (IC )H]
con max 50
Inhibitory sigmoid Emax curve.
Where:
• IC50 the inhibitory concentration that is 50% effective,
a measure of the antimicrobial agent’s potency
• H, the slope of the curve, or Hill factor and
• Econ is control bacterial population without treatment
Some classes of antimicrobial agents kill best
when concentration persists above MIC for
longer durations of the dosing interval. Indeed,
increasing the drug concentration beyond four to
six times the MIC does not increase microbial kill
for such antibiotics. Two good examples are β-
lactam antibacterials (e.g., penicillin) and the
antifungal agent 5-flourocytosine. The clinical
implication is that a drug optimized by T > MIC
should be dosed more frequently, or if possible
should have its t1/2 prolonged by other drugs, so
that drug concentrations persist above MIC (or
EC95) as long as possible. Thus, the effectiveness
of penicillin is enhanced when it is given as a
continuous infusion. Some antibiotics, such as
ceftriaxone (t1/2 = 8 h), have a long half-lives, such
that infrequent dosing several times a day still
optimizes T > MIC.
Ambrose et al., 2007; Andes and van Ogtrop, 2000
Conversely, the peak concentration is what matters
for other antimicrobial agents, meaning that these
drugs can be dosed more intermittently.
Aminoglycosides are a prime example of this class;
aminoglycosides are highly effective when given
once a day, with effectiveness continuing long after
antibiotic concentrations decline below the MIC.
Rifampin is such a drug. The entry of rifampin into
M. tuberculosis increases with increased
concentration in the bacillus microenvironment,
likely because of a saturable transport process.
Once inside the bacteria, the drug’s macrocyclic ring
binds the β subunit of DNA-dependent RNA
polymerase (rpoB) to form a stable drug-enzyme
complex within 10 min, a process not enhanced by
longer incubation of drug and enzyme and only
slowly reversed. The PAE of the rifampin is long and
concentration dependent.
Gumbo et al., 2007
There is a third group of drugs for which it is
the cumulative dose that matters, and for
which the daily dosing schedule has no effect
on efficacy. Thus, it is more ratio of the total
concentration (AUC) to MIC that matters and
not the time that concentration persists above
a certain threshold.
Antibacterial agents such as daptomycin fall

into this class. These agents also have a good
PAE. The AUC/IC50 explains why tenofovir and
emtricitabine (nucleoside analogue reverse
transcriptase inhibitors) have been combined
into one pill, administered once a day for the
treatment of AIDS.
Louie et al., 2001; Jung D. et al. 2004,

Summary of the Pharmacological basis for selection and
dosing schedules
• The optimal dose should be designed to achieve a high probability of exceeding

the EC80 microbial PK/PD index, or an index associated with suppression of
resistance, given the population pharmacokinetic variability and the MIC
distribution of clinical microbe isolates.
• The dose schedule is chosen according to whether efficacy is driven by AUC/MIC
(or AUC/EC95), CPmax/MIC, or T > MIC. Duration of therapy is then chosen based on
best-available evidence.
Types and Goals of Antimicrobial Therapy
Antimicrobial therapy–disease progression timeline.

Antimicrobial therapy–disease progression timeline:
Prophylaxis
Prophylaxis involves treating patients who are not
yet infected or have not yet developed disease. The
goal of prophylaxis is to prevent infection in some
patients or to prevent development of a potentially
dangerous disease in those who already have
evidence of infection. The main principle behind
prophylaxis is targeted therapy. An important
recent advance has been the understanding of the
roles of the human microbiome in health. The
biome is a critical defense against dangerous
infections and important in uptake of vaccines. So
extensive is the putative preventive role of the
microbiome includes common conditions such as
allergies, autism, cancer, antibiotic-associated
colitis, diabetes, and obesity. Thus, in routine
prophylaxis there is need to preserve the native
biome as much as possible.
Prophylaxis, please consider the following
• Consider narrow-spectrum antibiotics
targeted at the most important (potential
surgical site) infectious organisms and do
not target all possible bacteria.
• Limit the duration of prophylaxis to be

as short as the time in which maximum
contamination is expected (e.g., during
incisions and the surgical procedure) and
do not prolong beyond this time.
• Apply PK/PD thinking, as described

previously.
Prophylaxis in Immunosuppressed Patients
• Prophylaxis is used in immunosuppressed
patients such as those with HIV-AIDS or are
posttransplantation and on antirejection
medications. In these groups of patients,
specific antiparasitic, antibacterial, antiviral,
and antifungal therapy is administered based
on the well-defined pattern of pathogens that
are major causes of morbidity during
immunosuppression. A risk-benefit analysis
determines choice and duration of
prophylaxis. Prophylaxis of opportunistic
infections in patients with AIDS is started when
the CD4 count falls below 200 cells/mm3, and
In general, the prophylactic dose is lower than when
is discontinued when the CD4 count climbs
the same drug is used for acute treatment.
above 200 cells/mm3.
Centers for Disease Control and Prevention et al., 2000; DHHS Panel, 2015
Prophylaxis in Surgical Procedures
Prophylaxis in Patients at Risk of Infective Endocarditis
Patients at the highest risk for infective endocarditis for which prophylaxis is
recommended fall into four groups:
I. Those with a prosthetic material used for heart valve repair or replacement;
II. Patients having had previous infective endocarditis;
III. Patients with congenital heart disease such as unrepaired cyanotic heart
disease, or within 6 months of repair of the heart disease with prosthetic
material, or those with residual defects adjacent to prosthetic material; and
IV. Postcardiac transplant patients with heart valve defects.
Wilson et al., 2007

Prophylaxis in Patients at Risk of Infective Endocarditis
Chemoprophylaxis is reasonable when these patients undergo dental procedures
if there is manipulation of gingival tissue or the periapical region of teeth or
perforation of oral mucosa, but not for other dental procedures.
Recommended therapy is a single dose of oral amoxicillin 30 min to 1 h before
the procedure; intravenous ampicillin or ceftriaxone in those unable to take
oral medication; or macrolide or clindamycin for patients allergic to β-lactam
agents.
Therapy may be administered no more than 2 h after the procedure for patients
who failed to receive the prophylaxis prior to the procedure.
Wilson et al., 2007

Preemptive Therapy
Preemptive therapy is used as a substitute for universal prophylaxis and as early targeted
therapy in high-risk patients who already have a laboratory or other test indicating that an
asymptomatic patient is infected.
The principle is that delivery of therapy prior to development of symptoms aborts

impending disease, and the therapy is for a short and defined duration.
This has been applied in the clinic to therapy for CMV after both hematopoietic stem cell
transplants and after solid-organ transplantation.
When rapid turnaround tests (e.g., PCR based) are available, the preemptive strategy is
now more preferable than universal prophylaxis for CMV.
Gerna et al., 2008

Empirical Therapy in the Symptomatic Patient
The question is:
Should a symptomatic patient be treated immediately?
The answer is:

The reflex action to associate fever with treatable infections and
prescribe antimicrobial therapy without further evaluation is
irrational and potentially dangerous.
The first consideration in selecting an antimicrobial is to determine if the drug is indicated.
The diagnosis may be masked if therapy is started and appropriate cultures are not
obtained.
Antimicrobial agents are potentially toxic and may promote selection of resistant
microorganisms. For some diseases, the risk in waiting a few days is low, and these patients
can wait for microbiological evidence of infection without empirical treatment.
If the risks of waiting are high, based either on the patient’s immune status or other known
risk factors, then initiation of optimal empirical antimicrobial therapy should rely on the
clinical presentation and clinical experience.
In addition, simple and rapid laboratory techniques are available for the examination of
infected tissues..
The most valuable and time-tested method for immediate identification of bacteria is
examination of the infected secretion or body fluid with Gram stain.
In malaria-endemic areas, or in travelers returning from such an area, a simple thick-and-

thin blood smear may mean the difference between a patient’s survival on appropriate
therapy or death while on the wrong therapy for a presumed bacterial infection.
On the other hand, neutropenic patients with fever have high risks of mortality, and when
febrile, they are presumed to have either a bacterial or a fungal infection. Thus, a broad-
spectrum combination of antibacterial and antifungal agents that cover common infections
encountered in granulocytopenic patients is given.
Performance of cultures is still mandatory with a view to modify antimicrobial therapy with
culture results.
Definitive Therapy With Known Pathogen
Combination therapy is an exception in these cases:
• preventing resistance to monotherapy;
• accelerating the rapidity of microbial kill;
• enhancing therapeutic efficacy by use of
synergistic interactions or enhancing kill by a
drug based on a mutation generated by
resistance to another drug;
• reducing toxicity (i.e., when sufficient efficacy of
a single antibacterial agent can be achieved only
at doses that are toxic to the patient and a
second drug is coadministered to permit
lowering the dose of the first drug)
Posttreatment Suppressive Therapy
• In some patients, the infection is controlled
but not completely eradicated by the initial
round of antimicrobial treatment, and the
immunological or anatomical defect that led to
the original infection is still present. In such
patients, therapy is continued at a lower dose.
This is common in patients with AIDS and
patients posttransplant. The goal is more as
secondary prophylaxis. Nevertheless, risks of
toxicity from the long durations of therapy are
still real. In this group of patients, the
suppressive therapy is eventually discontinued
In general, the prophylactic dose is lower than when
if the patient’s immune system improves.
the same drug is used for acute treatment.
Centers for Disease Control and Prevention et al., 2000; DHHS Panel, 2015
Mechanism of Resistance to Antimicrobial Agents
• Antimicrobial agents were viewed as miracle cures
when first introduced into clinical practice. Today,
every major class of antibiotic is associated with the
emergence of significant resistance. Two major
factors are associated with emergence of antibiotic
resistance: evolution and clinical/environmental
practices. When a microbial species is subjected to
an existential threat, chemical or otherwise, that
pressure will select for random mutations in the
species’ genome that permit survival. Pathogens
will evolve to develop resistance to the chemical
warfare to which we subject them. This evolution is
greatly assisted by poor therapeutic practices by
healthcare workers and the indiscriminate use of
antibiotics in agriculture and animal husbandry.
There is a book you shoud read
Every living being is also a fossil. Within it, all
the way down to the microscopic structure of
its proteins, it bears the traces if not the
stigmata of its ancestry.
Jacques Monod (1910-1976)
Le hasard et la nécessité. Essai sur la philosophie naturelle de la biologie moderne, Ed. du Seuil, Paris 1970; Ed.
Italiana Il caso e la necessità. Saggio sulla filosofia naturale della biologia contemporanea, Mondadori, Milano
1971 ISBN: 9788804496076
• Antimicrobial resistance can develop at any one
or more of steps in the processes by which a drug
reaches and combines with its target. Thus,
resistance development may develop due to
• reduced entry of antibiotic into pathogen
• enhanced export of antibiotic by efflux pumps
• release of microbial enzymes that alter or

destroy the antibiotic
• alteration of target proteins
• development of alternative pathways to those Mechanisms by which such resistance develops can
inhibited by the antibiotic include acquisition of genetic elements that code for
the resistant mechanism, mutations that develop
under antibiotic pressure, or constitutive induction.
Mechanism of Resistance to Antimicrobial Agents:
Reduced entry of antibiotic into pathogen
• The outer membrane of gram-
negative bacteria is a
semipermeable barrier that
excludes large polar molecules from
entering the cell. Small polar
molecules, including many
antibiotics, enter the cell through
protein channels called porins.
Absence of, mutation in, or loss of a
favored porin channel can slow the
rate of drug entry into a cell or
prevent entry altogether, effectively
reducing drug concentration at the
target site.
Ouellette, 2001.
Enhanced export of antibiotic by efflux pumps
• Microorganisms can overexpress efflux pumps
and then expel antibiotics to which the microbes
would otherwise be susceptible. There are five
major systems of efflux pumps that are relevant
to antimicrobial agents:
• The multidrug and toxin extruder
• The major facilitator superfamily transporters
• The small multidrug resistance system
• The resistance nodulation division exporters
• ABC (ATP Binding Cassette) transporters (P-

Glycoprotein 1 is one of them)
• Efflux pumps are a prominent mechanism of
resistance for parasites, bacteria, and fungi.
One of the tragic consequences of resistance
emergence has been the development of drug
resistance by Plasmodium falciparum. Drug
resistance to most antimalarial drugs,
specifically chloroquine, quinine, mefloquine,
halofantrine, lumefantrine, and the
artemether-lumefantrine combination is
mediated by an ABC transporter encoded by
P. falciparum multidrug resistance gene 1
(Pfmdr1). Point mutations in the Pfmdr1 gene
lead to drug resistance and failure of
chemotherapy.
(Happi et al., 2009).
•Drug efflux sometimes works in
tandem with chromosomal
resistance, as is seen in
Streptococcus pneumoniae and M.
tuberculosis. In these situations,
induction of efflux pumps occurs
early, which increases the MIC only
modestly. However, this MIC
increase may suffice to allow
further microbial replication, a
continuation of mutation, and the
development of resistance via
more robust chromosomal
mutations.
(Gumbo et al., 2007b; Jumbe et al., 2006; Schmalstieg et al., 2012).
Release of microbial enzymes that alter or destroy the
antibiotic
•Drug inactivation is a common mechanism of
drug resistance. Bacterial resistance to
aminoglycosides and to β-lactam antibiotics
usually is due to production of an
aminoglycoside-modifying enzyme or β-
lactamase.
• A common consequence of either single-or
multiple-point mutations is a change in amino acid
composition and conformation of an antimicrobial’s
target protein. This change can lead to reduced
affinity of drug for its target or of a prodrug for the
enzyme that activates the prodrug. Such alterations
may be due to mutation of the natural target (e.g.,
fluoroquinolone resistance), target modification
(e.g., ribosomal protection type of resistance to
macrolides and tetracyclines), or acquisition of a
resistant form of the native, susceptible target (e.g.,
staphylococcal methicillin resistance caused by
production of a low-affinity penicillin-binding
protein).
(Hooper, 2002; Lim and Strynadka, 2002; Nakajima, 1999)
• In HIV resistance, mutations associated with reduced affinity
are encountered for protease inhibitors, integrase inhibitors,
fusion inhibitors, and nonnucleoside reverse transcriptase
inhibitors. Similarly, benzimidazoles are used against myriad
worms and protozoa and work by binding to the parasite’s
tubulin; point mutations in the β-tubulin gene lead to
modification of the tubulin and drug resistance.
Steffen SR et al.; Extreme allelic heterogeneity at a Caenorhabditis elegans beta-tubulin locus explains natural
resistance to benzimidazoles
(Nijhuis et al., 2009; Ouellette, 2001).
Incorporation of Drug
• An uncommon situation occurs when an
organism not only becomes resistant to an
antimicrobial agent but also subsequently
starts requiring it for growth. Enterococcus,
which easily develops vancomycin
resistance, can, after prolonged exposure
to the antibiotic, develop vancomycin-
requiring strains. In 1955, shortly after
introduction of streptomycin for
tuberculosis, Hashimoto isolated a
streptomycin-dependent mutant of M.
tuberculosis; it grows in the presence of the
antibiotic but goes into dormancy in the
absence of the streptomycin.
Resistance Due to Enhanced Excision of Incorporated Drug
• Nucleoside reverse transcriptase
inhibitors such as zidovudine are 2′-
deoxyribonucleoside analogues that
are converted to their 5′-
triphosphate form and compete
with natural nucleotides. These
drugs are incorporated into the viral
DNA chain and cause chain
termination. When resistance
emerges via mutations in the
reverse transcriptase gene,
phosphorolytic excision of the
incorporated chain-terminating
nucleoside analogue is enhanced.
Arion et al., 1998).
Heteroresistance and Viral Quasi-Species
Heteroresistance occurs when a subset of the
total microbial population is resistant, despite
the total population being considered
susceptible on testing. A subclone that has
alterations in genes associated with drug
resistance is expected to reflect the normal
mutation rates (occurrence in 1 in 106 to 105
colonies). In bacteria, heteroresistance has
been described especially for vancomycin in
S. aureus and Enterococcus faecium; colistin
in Acinetobacter baumannii-calcoaceticus;
rifampin, isoniazid, and streptomycin in M. Jemma L. Geoghegan and Edward C. Holmes, Genetics, Vol. , 1151–1162
December 2018
tuberculosis; and penicillin in S. pneumoniae
etc., etc.
(Falagas et al., 2008; Rinder, 2001; Hofmann-Thiel et al., 2009; Marr et al., 2001; Mondon et al., 1999).
Heteroresistance and Viral Quasi-Species
Viral replication is more error prone than
replication in bacteria and fungi. Viral evolution
under drug and immune pressure occurs relatively
easily, commonly resulting in variants or quasi-
species that may contain drug-resistant
subpopulations. This is not often termed
heteroresistance, but the principle is the same: A
virus may be considered susceptible to a drug
because either phenotypic or genotypic tests
reveal “lack” of resistance, even though there is a
resistant subpopulation just below the limit of
assay detection. These minority quasi-species that
are resistant to antiretroviral agents have been
associated with failure of antiretroviral therapy.
Jemma L. Geoghegan and Edward C. Holmes, Genetics, Vol. , 1151–1162 December 2018 Metzner et al., 2009
Development of Resistance via Mutation Selection
• Mutations may occur in the gene encoding the following:
• the target protein, altering its structure so that it no longer

binds the drug
• a protein involved in drug transport
• a protein important for drug activation or inactivation
• in a regulatory gene or promoter affecting expression of

the target, a transport protein, or an inactivating enzyme
Hypermutable Phenotypes
Genetic mutation is accomplished principally by
the replicative and repair activities of DNA
polymerases a continuity and postreplicative repair
systems. The development of a defect in one of
these repair mechanisms leads to a high degree of
mutations in many genes; such isolates are
termed mutator (Mut) phenotypes and may include
mutations in genes causing antibiotic resistance.
This second-order selection of hypermutable
(mutator) alleles based on alterations in DNA repair
genes has been implicated in the emergence of
multidrug-resistant strains of M.
tuberculosis Beijing genotype.
(Giraud et al., 2002; Rad et al., 2003)

Resistance by External Acquisition of Genetic Elements
• As described, drug resistance may be acquired
by mutation and selection, with passage of the
trait vertically to daughter cells, provided the
mutation is not lethal, does not appreciably
alter virulence, and does not affect replication
by the progeny. Drug resistance more
commonly is acquired by horizontal transfer of
resistance determinants from a donor cell,
often of another bacterial species, by
transduction, transformation, or conjugation.
Resistance by External Acquisition of Genetic Elements
• Resistance acquired by horizontal
transfer can disseminate rapidly
and widely either by clonal spread
of the resistant strain or by
subsequent transfers to other
susceptible recipient strains.
Horizontal transfer of resistance
offers several advantages over
mutation selection. Lethal mutation
of an essential gene is avoided; the
level of resistance often is higher
than that produced by mutation,
which tends to yield incremental
changes.
Horizontal Gene Transfer
Horizontal transfer of resistance
genes is greatly facilitated by
mobile genetic elements. Mobile
genetic elements include plasmids
and transducing phages. Other
mobile elements—transposable
elements, integrons, and gene
cassettes—also participate.
Transposable elements are of three
general types: insertion sequences,
transposons, and transposable
phages. Only insertion sequences
and transposons are important for
resistance. There are numerous
modes of horizontal resistance
transfer:
Horizontal Gene Transfer: Transduction
• Acquisition of bacterial DNA
from a phage (a virus that
propagates in bacteria) that
has incorporated DNA from a
previous host bacterium
within its outer protein coat.
If the DNA includes a gene for
drug resistance, the newly
infected bacterial cell may
acquire resistance.
Transduction is particularly
important in the transfer of
antibiotic resistance among
strains of S. aureus.
Horizontal Gene Transfer: Transformation
• Uptake and incorporation into
the host genome by
homologous recombination of
free DNA released into the
environment by other bacterial
cells. Transformation is the
molecular basis of penicillin
resistance in pneumococci
and Neisseria.
Horizontal Gene Transfer: Conjugation
• Gene transfer by direct cell-
to-cell contact through a sex
pilus or bridge, allowing the
transfer of multiple resistance
genes in a single event. The
transferable genetic material
consists of two different sets
of plasmid-encoded genes on
the same or different
plasmids: one encoding the
actual resistance, and another
encoding genes necessary for
bacterial conjugation.
Examples of acquired resistance through mutation and
horizontal gene transfer
In conclusion, remember
“Humanity is just a speck in

the massively bacterial world”
Bacteria = 5,000,000,000,000,000,000,000,000,000,000 = 5 million trillion trillion = 5 x 1030
Humans = 7,600,000,000 = 7.6 billion = 7.6 x 109

Resistance to Antimicrobial Agents:
The recent story of mcr-1.
A startling example is that of the
plasmid-mediated colistin resistance
gene (mcr-1), which confers resistance
to one of the last-resort antibiotics for
multidrug-resistant gram-negative
bacteria. Colistin is used in agriculture
and animal husbandry. Escherichia coli
strains carrying this gene were found in
pigs, then in pork, and then in patients.
The plasmid carrying mcr-1 was
mobilized by conjugation to E. coli at a
frequency of 10−1 to 10−3 cells.
Hadjadj L., et al., Genes 2017, 8(12), 394; Liu et al., 2016.
Resistance to Antimicrobial Agents:
The recent story of mcr-1…. “Begun the clone war has!”
The resistant bacteria were initially
identified in China, but within months
isolates were also identified in North
America, South America, Europe, East
Asia, and Africa and in other
organisms, such as Salmonella
typhimurium. The gene has now been
demonstrated in gut microbiota of
healthy individuals, suggesting
integration in the human gut and the
capacity to spread to organisms in the
human microbiome.
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001 - General Principles of Antimicrobial Therapy

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“Corso di Laurea in Medicina e Chirurgia”

Insegnamento di Farmacologia 1 – IV anno – Programma di Chemioterapia AA 2019-2020

1. General Principles of Antimicrobial Therapy

This presentation is updated to September 24th , 2019.

Sir Charles Darwin

• These books would build an 80 mt. tower

• We and Aristotle are on the same last page

The biochemical processes commonly

Recently, antisense antibiotics have been

Furthermore, interferon-based products

Kane et al., 2016, Cell Host & Microbe 20, 392–405

Classification of an antibiotic is based on the following:

• class and spectrum of microorganisms it kills

E = Econ – Emax x (IC)H/[(IC)H+ (IC50)H]

b) The chemical properties of the drug

c) The presence of multidrug transporters

• Inducible biotransforming enzymes. The major drug-metabolizing systems are inducible,

Kiem S., and Schentag JJ, Antimicrob. Agents Chemother. 2008

(Chigutsa et al., 2015; Rodríquez-Tudela et al., 2007)

Antibacterial agents such as daptomycin fall

Louie et al., 2001; Jung D. et al. 2004,

• The optimal dose should be designed to achieve a high probability of exceeding

Antimicrobial therapy–disease progression timeline.

• Limit the duration of prophylaxis to be

• Apply PK/PD thinking, as described

Wilson et al., 2007

Wilson et al., 2007

The principle is that delivery of therapy prior to development of symptoms aborts

Gerna et al., 2008

The answer is:

In malaria-endemic areas, or in travelers returning from such an area, a simple thick-and-

• reduced entry of antibiotic into pathogen

• enhanced export of antibiotic by efflux pumps

• release of microbial enzymes that alter or

• alteration of target proteins

• The multidrug and toxin extruder

• The major facilitator superfamily transporters

• The small multidrug resistance system

• The resistance nodulation division exporters

• ABC (ATP Binding Cassette) transporters (P-

• Mutations may occur in the gene encoding the following:

• the target protein, altering its structure so that it no longer

• a protein involved in drug transport

• a protein important for drug activation or inactivation

• in a regulatory gene or promoter affecting expression of

(Giraud et al., 2002; Rad et al., 2003)

“Humanity is just a speck in

Bacteria = 5,000,000,000,000,000,000,000,000,000,000 = 5 million trillion trillion = 5 x 1030

Humans = 7,600,000,000 = 7.6 billion = 7.6 x 109

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