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Inhibition of cell wall synthesis--is this the mechanism of action of

penicillins?

Article  in  Medical Hypotheses · March 1995

DOI: 10.1016/0306-9877(95)90085-3 · Source: PubMed

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 Medical Hypotheses
Medical Hypotheses, (1995), 44, 127-131
© PearsonProfessional1995

Inhibition of Cell Wall Synthesis -Is this the

Mechanism of Action of Penicillins?

R.B. GHOOI and S.M. THATTE

The Medical Division, Unichem Laboratories Ltd, S.V. Road, Jogeshwari, (West) Bombay 400 102, India

Abstract - - Penicillins have been shown to inhibit bacterial cell wall synthesis, and interact with
penicillin binding proteins, leading to bacterial lysis. These two mechanisms, the former more
than the latter are believed to be responsible for their therapeutic potential. It has further been
demonstrated that only actively multiplying cells are susceptible to bactericidal effects of the
antibiotic, which is in accordance with the suggested mechanism of action.
Bacterial growth takes place in terms of size and number, both requiring additional cell wall. An
increase in bacterial size is due to an icrease in the volume of cytosol and area of the cell wall.
Presently there is no proof that the former is the cause of the latter or vice versa. Penicillin by
inhibiting cell wall synthesis would inhibit both growth and multiplication. Since the antibiotic is
bactericidal to rapidly multiplying cells, its effect on cell wall would interfere with its bactericidal
action.
As per the present understanding penicillin acts principally by inhibiting cell wall synthesis.
There is however a discrepancy between its observed effects and what should logically be
expected, which forces us to reexamine the mechanism of action of penicillin. We believe that
the present understanding of the action of penicillin is incomplete if not outright faulty. It would be
expedient to radically modify the same in view of its implication, for example on drug development.

Introduction important is not the sole mechanism of action. Ad-

Ever since the discovery of penicillins by Sir Alexan-
der Flemming, it is believed that this group of drugs
acts by the inhibition of cell wall synthesis. All the
evidence obtained so far proves this to be the most ob-
vious mechanism, hence it is believed to be the most
important. Acceptance of this mechanism, however,
puts certain conditions on the antibacterial effects of
the antibiotic, which merit examination.
Penicillins have been demonstrated to inhibit the
enzyme transpeptidase, thus preventing synthesis of
peptidoglycan, which is an important constituent of
the bacterial cell wall (1). This effect, though very
ditional targets for penicillin action are collectively
known as Penicillin Binding Proteins (PBPs). Interac-
tion with PBPs causes activation of autolysins leading
to bacterial death (2).
Antibiotics, in general and penicillins in particular
are known to have best activity on rapidly growing
young cultures of susceptible bacteria, since only they
have higher metabolic requirements (3). By defini-
tion, at and above MIC levels, inhibitory effects of
penicillins become evident, and bacterial cells are pre-
vented from growing further (bacteriostatic action).
At concentrations exceeding the minimum bacterici-
dal concentration (MBC), active bacterial lysis takes

Date received 18 April 1994

Date accepted 2 May 1994
127
 128
place, though it is not clear by what mechanism (4,5).
MBC is generally two or three fold higher than MIC,
and varies from organism to organism (6,7).
The limitation of the presently accepted hypothesis
is that, penicillins would inhibit cellular growth, in
size and number, by their effect on cell walls. Peni-
cillins thus prevent bacterial growth and have an ini-
tial bacteriostatic effect, a hypothesis which was valid
once (8) but no longer seems to be valid. Such an
effect is incompatible with their bactericidal action.
Two mechanisms, of which one inhibits growth and
one causes lysis of rapidly dividing bacteria are not
synergistic but antagonistic. The early effects of peni-
cillins are thus not compatible with the bactericidal
effects. The same reason is cited for the axiom that
bacteriostatic and bacteriocidal antibiotics should not
be co-administered (9).
Effects of penicillin have been studied on many
types of bacteria in different phases of growth. These
studies have demonstrated that rapidly growing cells
are maximally affected by penicillins. Kill kinetics of
penicillins have not however answered some ques-
tions, probably because they were not asked. In this
paper we discuss aspects of bacterial growth and the
pharmacokinetics of penicillins which have bearing
on the mechanism of action of this group of antibi-
otics.
We propose that inhibition of cell wall synthesis
is not the major mechanism of bactericidal action of
penicillins, as previously thought. It is probably one
of the undesirable effects of penicillins, which hin-
ders full bactericidal action of the antibiotic. Due to
its static action it prevents further multiplication and
thus interferes with its action. A derivative with lesser
effect on cell walls, but retaining other actions might
turn out to be a more potent antibiotic.
In depth studies are required to identify the mech-
anism of action of penicillin. Should these studies
prove that penicillins do act by inhibiting cell wall
synthesis then a radical change in drug development
is called for. Newer penicillins need to be developed
which would have a very short half life, and can be
administered at a much higher frequency. Short acting
antibiotics given every 1 or 2 h can be expected to
have a better therapeutic action than long acting ones,
when their spectra match.
Another compelling reason to take up these investi-
gations is the problem of antibiotic resistance. Despite
the advances made in the field of antibiotics, bacterial
resistance continues to be the major hurdle in success-
ful chemotherapy. It would be essential to have an in
depth understanding of the action of the antibiotic be-
fore the problem of resistance is successfully tackled.
MEDICALHYPOTHESES
Bacterial growth
Bacteria are of two principal types, cocci and bacilli.
In order to calculate the relation of their cell surface
area (which is similar to the area of the cell wall)
to cellular volume, we have assumed that cocci are
spherical and bacilli have a length which is four times
their thickness, as shown in Figure 1.
Intracellular Volume Surface Area
r
40 Units 3 56,55 Units 2
, J
Cocci
3
40 Units 61,40 Unlts 2
Bacilli
Fig. 1 Cocci and bacilli.
Bacteria, whether cocci or bacilli, may grow in two
ways, in number and in size. In fact both types of
growth are evident in any normal bacterial colony.
Absence of multiplication will permit growth in size
but not in number, leading to the formation of gi-
ant bacterial cells which would become non-viable
beyond a particular size (Fig. 2). Multiplication of
bacteria without growth will reduce the size of the
cell to a non-functional one within 4 to 5 generations
as shown in Table 1.
For a healthy bacterial colony, growth in size and
number both together is an essential factor. Any at-
tempt to eradicate such a colony must take into con-
sideration that increase in size and number is taking
place continually. Any arrest of growth might convert
the colony into a dormant non-growing one which is
less sensitive to the effects of a number of antibiotics.
Antibiotic action
Antibiotics may arrest one or more different steps
in bacterial metabolism. Many antibiotics act on cell
wall synthesis (penicillins and cephalosporins), while
others act on protein synthesis. Their mechanism of
action decides whether they would be bacteriostatic
PENICILLINS AND INHIBITION OF CELL WALL SYNTHESIS 129

Table 2

Surface Area In Square Units

70 Agent Half li[e (h) Dosage interval (h)
60
Penicillin G 0.5 4 - 6
5O Cefoxitin 0.7 4 - 6
40 Ampicillin 1.0 4 - 6
Cefazolin 1.5 6 - 8
3O Cefuroxime 1.7 8- 12
Ceftazidime 2.0 8- 12
~0 ............................................................................................................................................................................
Cefonicid 4.5 12 - 24
l O ................................................................................................................................................................................... Ceftriaxone 8.0 12 - 24

0
10 20 30 40 (From 13, 14).
Volume In Units Cubed

Cocci "-+- Bacilli Figure 3 shows the computed serum concentration

curve of ampicillin where doses of 1000 mg (qds)
Fig. 2 Cellular growth and cell wall area in the absence of multi- have been given to a patient of 60 kg, the apparent
plication. volume of distribution being 0.28 L/kg and a t max
of 30 min. The curve shows that sufficient serum con-
centrations are not maintained throughout, but levels
Table 1 Effect of multiplication (without growth) on cell fall below MIC before a second dose is administered.
surface area

Generation Number of Volume qf Total sur~ctce Concentration in mcg/ml

70
cells each cell area
6 0 ......................................................................................................................................................................................................

I l 80 89.54
50
l 2 40 112.9
Ill 4 20 141.8 40
1V 8 10 180.4
V 16 5 225.76 30

20

10
or bactericidal in concentrations which are therapeu- 0
tically achieved. 0 I 2 4 6 8 12 16 18 20 24

Two important pharmacokinetic parameters deter- Time in Hours

mine the main and adverse effects of drugs, these are
Series 1
the C max and the AUC. So far it is not clear whether
C max is more important than AUC, or vice versa in
t m a x • 0.5 h, l 1/2 • I h
case of antibiotics (10). There appear to be two groups
of antibiotics, with differing relation of kill kinetics to
Fig. 3 Serum concentration of ampicillin multiple dose kinetics.
C max. In the first group, killing rate is continually
parallel to antibiotic concentration, while in the sec-
ond, kill rate is related to the C max only in the initial In comparison with ampicillin if a beta-lactam with
period (11). Penicillins have been demonstrated to fall higher half life such as cefonicid is injected at a dose
in the second group of antibiotics. We have used com- which produces an equivalent C max, the AUC is
puted serum concentration curves which would hope- much higher. If such a compound is given at an inter-
fully throw more light on the effects of the antibiotic val of 6 h the blood level is not only maintained but an
on microorganisms, in line with other mathematical ascending staircase phenomenon is seen (Fig. 4). The
models (12). peak serum level rises initially, as does the trough. It
Pharmacokinetically AUC is directly related to half may come to pass that the trough is maintained well
life if the dose and the apparent volume of distribution above the MIC for sensitive organisms, thus causing
is similar. In the penicillin family one finds represen- long lasting inhibition of bacterial growth. Such phar-
tatives with widely varying half lives, as shown in macokinetics will not aid bactericidal effect but are
Table 2. likely to lead to toxicity and resistance. The drawback
130
o f such an antibiotic is that it can induce a single
effective bactericidal peak in a day, and attempts to
use it more frequently will be counterproductive.
Concentr~lon In m c g / m l
120
IOO
80
60
40
20
o autolysins. Effect on bacterial cell wall is one of its
0 l 2 4 6 8 12 16 18
Time in Hours
C,lonlcld 400 mg qd
I max • 0,5 h,
Fig. 4 Serum concentration of cefonicid multiple dose kinetics.
Attempts are being made to develop penicillins
(and related compounds like cephalosporins) with a
higher biological half life, and hence suitable for once
a day administration. Such agents produce serum con-
centration curves akin to that of cefonicid. Newer
agents may thus be easier to administer (once a day)
but not necessarily superior in action.
On the contrary, short acting penicillins would
hopefully achieve high levels on administration,
which rapidly fall below MIC levels. Bactericidal ac-
tion would peak at tmax, and when antibiotic levels
fall well below MIC, bacterial growth takes place,
hence subsequent doses would have better bacterici-
dal action on these growing cells. Since such antibi-
otics can be administered a number of times daily, re-
peated attacks on bacteria are possible within a single
24 h period.
Antibiotics whether of the penicillin class or of a
different class, have two attributes, ease o f adminis-
tration and efficacy. Short acting agents may suffer
from poor compliance, but will have a superior effi-
cacy. It is proposed that if a choice has to be exerted,
synthetic chemists should sacrifice compliance for ef-
ficacy rather than the other way round. Short acting
penicillins should be the trend for the future and not
long acting agents.
Effects on cell wall synthesis may explain the ar-
rest of bacterial growth by penicillins, however, an-
other mechanism is essential for the action of peni-
cillins on non-growing bacteria. Present knowledge
MEDICALHYPOTHESES
suggests that either inactivation or the loss of an au-
tolysin inhibitor could be responsible for damage to
non-growing cells. Both these mechanisms release ac-
tive autolysin in the medium, which sets up a chain
reaction lysing whole cells. In fact bacterial lysis ini-
tiated by an autolytic mechanism would be similar
to a chain nuclear reaction, and could go on in the
absence of antibiotic. Though it has been shown that
penicillin kill rates are dependent on concentration
only in the initial period, total dissociation of kill rate
and concentration is not observed.
Thus both the mechanisms proposed for penicillin
do not answer questions which are raised. It is pro-
posed that the main mechanism of action of peni-
cillins is probably apart from their actions on bacterial
20
undesirable effects and hinders full bactericidal action
of the antibiotic. A derivative with lesser effect on cell
walls, but retaining other actions might turn out to be
a more potent antibiotic.
Acknowledgements
The authors are grateful to Dr P.A. Mody, Managing Director,
Unichem Laboratories Ltd, for facilities granted in preparation of
this hypothesis.
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