CHAPTER 5 - ANTIMICROBIAL AGENTS

Therapeutic Index
Quinine from tree bark was long used to treat malaria (1854-1915)
Paul Ehrlich - German Physician
● Proposed the term “selective toxicity” - that would kill
pathogens and not human cells
● Dye trypan – trypanosome
● Arsenicals – syphilis-infected rabbits
● Arsphenamine / Salvarsan - syphilis spirochetes
● The ratio of the toxic dose to the therapeutic dose
● The larger the therapeutic index, the better the
chemotherapeutic agent.
Side Effects
● Undesirable effects on the host and it may involve almost any
organ system
● Chemotherapeutic agents must be administered with care

Alexander Fleming Range of Effectiveness - it depends on the situation

● Penicillin (1896) 1. Narrow–Spectrum Drugs
● He observed that Penicillium fungus produced an antibiotic, ● Effective only against a limited variety of pathogens.
penicillin, that killed S. aureus. ● Used for known etiologic agents

Domagk 2. Broad–spectrum Drugs

● Prontosil Red – for pathogenic streptococci and staphylococci in ● Attack many different kinds of pathogens.
mice. ● Used for unknown etiologic agents.
● Sulfonamides or sulfa drugs (1939)
Agents on General Microbial Group
Ways to Express Degree of Selective Toxicity 1. Antibacterial
1. Therapeutic dose 2. Antifungal
● The drug level required for clinical treatment of a particular 3. Antiprotozoal
infection. 4. Antiviral
● Low Therapeutic dose is ideal because it needs a small amount of
drug to treat a disease.

2. Toxic dose
● The drug level which the agent becomes too toxic for the host.
● The drug must have a low amount of toxic dose.
Chemotherapeutic Agents WAYS OF CLASSIFYING ANTIBACTERIAL AGENTS
● Can be synthesized by microorganisms or manufactured by ● According to whether they are bactericidal or bacteriostatic
chemical procedures independent of microbial activity ● Target site
1. Natural - totally synthesized by one of a few bacteria or fungi. ● Chemical Structure
2. Synthetic - produced by chemical synthesis
○ Sulfonamide BACTERICIDAL VS. BACTERIOSTATIC
○ Trimethoprim 1. Cidal - kills the target pathogen; its activity is concentration
○ Chloramphenicol dependent and the agent may be only static at low levels
○ Ciprofloxacin 2. Static - inhibit growth; if agent is removed, the microorganisms
○ Isoniazid will recover and grow again
○ Dapsone ● not effective if host’s resistance is too low
● i.e. immunocompromised patients
3. Semisynthetic - Natural antibiotics that have been chemically ● There are agents that are capable of killing some species,
modified by the addition of extra chemical groups to make them but are only bacteriostatic for others
less susceptible to inactivation by pathogens. ● Ex. Chloramphenicol
○ Ampicillin ○ Inhibits growth of E. coli but kills Haemophilus
○ Carbenicillin infuenzae
○ Methicillin ● ALL protein synthesis inhibitors and antimetabolites are
“static” except aminoglycosides
Antibiotics ● Others are “cidal”
- A substance produced by microorganisms that, in small amounts,
inhibits another microorganism. ACTIONS OF ANTIMICROBIAL DRUGS
1. Inhibition of cell wall synthesis
SOURCES OF ANTIBIOTICS 2. Inhibition of protein synthesis
3. Injury to plasma membrane
4. Inhibition of nucleic acid synthesis
5. Antimetabolites
 PROPERTIES OF SOME COMMON DRUGS IN ANTIBACTERIAL
DRUGS
DRUG PRIMARY SPECTRUM SIDE EFFECTS
EFFECT

Ampicillin cidal Broad gm (+) and some gm Allergic responses (Diarrhea, anemia)
(-)

Bacitracin cidal Narrow gm (+) Renal injury if injected

Carbenicillin cidal Broad gm (+), many gm (-) Allergic responses (nausea, anemia)

Cephalosporin cidal Broad gm (+), some gm (-) Allergic responses, thrombophlebitis,

s renal injury

Chloramphenic static Broad gm (+) and gm (-), Bone marrow dysfunction, allergic rxns
ol rickettsia and chlamydia

Chemical Structures of Antibacterial Agents Ciprofloxacin cidal Broad gm (+), gm (-) GIT upset, allergic rxns
● Not practical to use alone
Clindamycin static Narrow gm (+), anaerobes diarrhea
● Combination of chemical structure and target site provides
useful working classification. Dapsone static narrow (mycobacteria) Anemia, allergic responses

Erythromycin static Broad gm (+) and some gm GIT upset, hepatic injury
CLASSIFICATION BASED ON STRUCTURES: (-)

● Beta- lactams Gentamicin cidal Narrow gm (-) Allergic responses, nausea, loss of
● Glycopeptides hearing, renal damage

● Aminoglycosides Isoniazid static and Narrow (mycobacteria) Allergic rxns, GIT upset, hepatic injury
● Tetracyclines cidal

● Chloramphenicol Methicillin cidal narrow gm (+) Allergic rxns, renal toxicity, anemia
● Macrolides
Penicillin cidal Narrow gm (+) Allergic rxns, nausea, vomiting
● Lincosamides
● Fusidic acid Polymicin B cidal Narrow gm (-) Renal damage, neurotoxic rxns

● Sulfonamides Rifampin static Broad gm (+), Hepatic injury nausea, allergic responses
● Trimethroprim mycobacteria

● Quinolones Streptomycin cidal narrow gm (+) Allergic rxns, renal toxicity, anemia
● Rifampicin
EFFECTIVENESS OF CHEMOTHERAPEUTIC AGENT AGAINST
A PATHOGEN CAN BE OBTAINED FROM:
● Minimum Inhibitory Concentration
○ MIC is the lowest concentration of a drug that
prevents growth of a particular pathogen.
● Minimum Lethal Concentration
○ MLC is the lowest drug concentration that kills the
pathogen
Stoke’s Controlled Sensitivity Test
Principle:
● A control organism is inoculated on part of a plate and the
test organism is plated on the remainder.
● Disks are placed at the interface and the zones of
inhibition are compared.
● The use of a sensitive control shows that the antibiotic is
active, so that if the test organism grows up to the disk it
may safely be assumed that the test organism is resistant
to that drug.

Cidal - kills pathogens at levels only 2-4x the MIC

Static – kills at much higher concentrations

Antimicrobial Susceptibility Testing

1. Diffusion Methods
○ Commonly used in vitro tests in the laboratory
○ Inexpensive, easy to perform
○ Examples:
i. Kirby Bauer Disk Diffusion Test
ii. Stoke’s Test

2. Broth Dilution Tests

Kirby Bauer / Disk Diffusion Test
● A standardized suspension of organisms is inoculated onto
Mueller-Hinton agar.
● Paper disks impregnated with specific antibiotic
concentrations are placed into the agar.
● After 18-24 hours of incubation, diameters of zones
of inhibition are measured.
● Results are compared with established values to
determine the organism’s susceptibility or resistance to
each antibiotic.
The Etest
● Etest is the first in a new generation of novel products for
Antimicrobial Resistance Testing.
● Etest comprises a predefined gradient of antibiotic
concentrations on a plastic strip. It is used to determine
the exact Minimum Inhibitory Concentration (MIC) of
antibiotics, antifungal agents and antimycobacterial agents.
Minimum Inhibitory Concentration (MIC)
● Purpose:
○ For microorganisms with unpredictable
susceptibilities
○ MIC is the first broth (in tube) in which growth of
the organism has been inhibited.The more resistant
an organism is, then the higher will be the MIC.
Minimum Bactericidal Concentration (MBC)
● Purpose:
○ For microorganisms with unpredictable
susceptibilities
○ For treatment of serious infections
○ To minimize toxicity effects of drugs

Dilution Tests
1. Tube Dilution
2. Agar Dilution

MIC and MBC Determinations are

done with dilution assays
Testing of antibiotic combinations ● Synergistic
● Purpose: ○ The result with (2) drugs is significantly better
○ For mixed infections than the additive response
○ Prevention of development of bacterial resistance ○ 1 + 1 = 3 (e.g. static + static)
○ For minimizing toxicity effects
○ When combination therapy would be better option ● Potentiation
○ 0 + 1 = 2 (e.g. beta-lactamase inhibitor + Antibiotic)
Terminologies ○ Unasyn (Sulbactam + Ampicillin) ; Co-amoxiclav
● Autonomous/Indifferent (Clavulanic acid + Amoxicillin) ; Pipertazo
○ The result with (2) drugs is equal to the (Tazobactam + Piperacillin).
result with the most effective drug by
itself. Antimicrobial Resistance
● Antagonistic ● Requires interruption of one or more of the steps
○ The result with (2) drugs is significantly less than essential for effective antimicrobial action
the best individual response ● Results to partial or complete loss of antibiotic
○ 1+1=0 effectiveness
○ Static + cidal
Mechanisms of Antimicrobial Resistance
● Additive 1. Destruction or inactivation of the drug
○ The result with (2) drugs is equal to the combined 2. Prevention of penetration to target site within the microb
action of each of the 3. Alteration of drug’s target sites
○ drug used separately 4. Rapid efflux, which pumps the drug out of the cell before
○ 1+ 1 = 2 it can become effective.
○ e.g. cidal + cidal except Penicillin + Aminoglycoside
synergistic Addressing Antimicrobial Resistance
1. Modification of existing drugs
2. Identifying other targets for antimicrobial activity
3. Development of antimicrobial peptides from other sources