LICEO DE CAGAYAN UNIVERSITY

Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City

COLLEGE OF PHARMACY

BETA LACTAMASE INHIBITORS AND MACROLIDES

-Lactam Antibiotics

• The name lactam is given to cyclic amides with four atoms in its ring and is analogous to the name
lactone given to cyclic esters.
• Azetidinone - contemporary name for this ring system.
• It was found to be a feature of the structure of the penicillin.
• The penicillin subclass of β-lactam antibiotics is characterized by the presence of a substituted
five-membered thiazolidine ring fused to the β-lactam ring.
• This fusion and the chirality of the β-lactam ring result in the molecule roughly possessing a “V”
shape.

HISTORY

• Earliest penicillin was produced by fungi from media constituents.

• Bicyclic heterocyclic nucleus of 6-aminopenicillanic acid is constructed by a process catalyzed by
enzymes.
• was discovered that certain aryl acetic acids, when added to the medium, were used to form the
side chain amide moiety and that this was very important for stability and breadth of spectrum.
• It was later discovered that exclusion of such materials from the medium allowed the production
of 6-aminopenicillanic acid without a side chain.
• Later work produced the carbapenems, monobactams, and β-lactamase inhibitors.

Figure 1. Shows the 4 member ring structure of beta-lactam (Highlighted in red)

 LICEO DE CAGAYAN UNIVERSITY
Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
COLLEGE OF PHARMACY
• All beta-lactam antibiotics contain the same core 4 member ring.
• This ring mimics the d-alanyl-d-alanine peptide sequence that serves as the substrate for cell wall
transpeptidase that form covalent bonds between different peptidoglycan chains during periods
of cell growth.

MECHANISM OF ACTION

• The molecular mode of action of the β-lactam antibiotics is a selective and irreversible inhibition
of the enzymes processing the developing peptidoglycan layer.
• Just before cross-linking occurs, the peptide pendant from the lactate carboxyl of a muramic acid
unit terminates in a d-alanyl-d-alanine unit. The terminal d-alanine unit is exchanged for a glycine
unit on an adjacent strand in a reaction catalyzed by a cell wall transamidase.
• Cell wall transamidase uses a serine hydroxyl group to attack the penultimate d-alanyl unit
o forming a covalent ester bond
o the terminal d-alanine, which is released by this action, diffuses away.
• The enzyme– peptidoglycan ester bond is attacked by the free amino end of a pentaglycyl unit of
an adjacent strand, regenerating the transpeptidase’s active site for further catalytic action and
producing a new amide bond, which connects two adjacent strands together.
• The penicillins and the other β-lactam antibiotics have a structure that closely resembles that of
acylated d-alanyl-d-alanine. The enzyme mistakenly accepts the penicillin as though it were its
normal substrate. The highly strained β-lactam ring is much more reactive than a normal amide
moiety, particularly when fused into the appropriate bicyclic system.

RESISTANCE

Resistance to β-lactam antibiotics is unfortunately increasingly common and is rather alarming.

• It can be intrinsic
• Involve decreased cellular uptake of drug
• Involve lower binding affinity to Penicillin binding protein (PBPs)

Resistance to β-lactam antibiotics predominantly occurs in the following mechanism:

1. The production of β-lactamases, which is the most common resistance mechanism in Gram-
negative bacteria.
2. The production of an altered PBP with a lower affinity for most β-lactam antibiotics.

For Example:

The case with Methicillin-resistant staphylococcus aureus (MRSA). MRSA produces a mutated PBP-2
(PBP-2a) that does not efficiently bind methicillin any longer. In MRSA, the key resistance determinant
 LICEO DE CAGAYAN UNIVERSITY
Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
COLLEGE OF PHARMACY
is the production of PBP2a, which, as mentioned earlier, is much less efficiently inhibited by β-lactam
antibiotics compared to native S. Aureus PBPs.

PBP2 and PBP2a function together to provide the transpeptidation and transglycosylation activities
necessary to crosslink peptidoglycan and construct a functional cell wall even in the presence of β-
lactam antibiotics.

Based upon these resistance mechanisms, there are essentially two options to allow the continued
employment of β-lactam antibiotics

1.) design new β-lactam antibiotics that are not affected by the above mentioned bacterial
resistance mechanisms
2.) combine current β-lactam antibiotics with a drug that disables the resistance mechanisms.

BETA-LACTAM RESISTANT BACTERIA

❖ Haemophilus influenzae
❖ Bacteroides fragilis
❖ Escherichia coli
❖ Klebsiella spp.
❖ Acinetobacter spp.
❖ Pseudomonas aeruginosa
❖ Proteus spp.

BETA-LACTAM INHIBITORS (DRUGS)

STRUCTURE FIRST GENERATION DRUGS MECHANISM OF PHARMACOKINETIC

ACTION
Clavulanic Acid Clavulanic acid Clavulanic acid
• Clavulanic acid is a mold inactivates some beta- along with
product that has only lactamase enzymes amoxicillin is well
weak intrinsic that are produced by absorbed in the
antibacterial activity but bacteria, therefore stomach after oral
is an excellent irreversible preventing enzymatic administration
inhibitor of most β- destruction of without having any
lactamases. It is believed amoxicillin. impact of fasting
to acylate the active site and fed state on the
serine by mimicking the pharmacokinetics of
normal substrate. amoxicillin.
• Natural product from
streptomyces.
LICEO DE CAGAYAN UNIVERSITY
Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
COLLEGE OF PHARMACY
• Normally used in
combination with
amoxicillin and other
beta-lactamase sensitive
penicillin. When
clavulanic acid is added to
amoxicillin and ticarcillin
preparations, the potency
against β-lactamase–
producing strains is
markedly enhanced.
Sulbactam Sulbactam is an Sulbactam, a new
• Sulbactam is prepared by irreversible inhibitor beta-lactamase
partial chemical synthesis of beta-lactamase; by inhibitor, has
from penicillin. binding and inhibiting pharmacokinetic
• The oxidation of the sulfur beta-lactamase characteristics in
atom to a sulfone greatly produced by bacterial humans similar to
enhances the potency of cells, sulbactam is those of ampicillin
sulbactam. thereby able to and amoxicillin. Its
• The combination of prevent it from half-life in humans is
sulbactam and ampicillin reducing antibiotic approximately 1 h.
(Unasyn) is also clinically activity.
popular. The presence of
sulbactam in formulations
with ampicillin effectively
extends the antibacterial
spectrum of ampicillin to
include many bacteria
normally resistant to it
and to other beta-lactam
antibacterial.
Tazobactam Tazobactam inhibits • Administered
• Tazobactam is often co- the action of bacterial parenterally
administered with beta-lactamase (IM, IV
piperacillin because of producing organisms, • Rapid
tazobactam’s ability to which are normally distribution
inhibit β-lactamases. resistant to beta- within 30
• Tazobactam, like other β- lactam antibiotics. minites
lactamase inhibitors, has • Excretion via
little or no antibacterial kidneys
activity.
 LICEO DE CAGAYAN UNIVERSITY
Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
COLLEGE OF PHARMACY
DRUG INDICATIONS
• used in fixed combination with specific penicillin; ampicillin, amoxicillin or ticarcillin
• penicillin -lactamase inhibitor combinations are used for empirical therapy against a wide range
of potential pathogens including treatment of aerobic & anaerobic infections.
• The -lactam inhibitor merely extended the activity of the combined penicillin.

SIDE EFFECTS
• Allergic reactions (anaphylaxis)
• Superinfections (candidiasis)
• Nausea, gastrointestinal upset, diarrhea, taste disturbance
• Clavulanate: Increased gastrointestinal side effects

CONTRAINDICATIONS
• Hypersensitivity to other beta-lactam
• Hepatic or renal disease
• Pregnancy and Breastfeeding

DRUG INTERACTIONS:
• Aminoglycoside antibiotics
• Oral contraceptive medications

SECOND GENERATION DRUGS MECHANISM OF ACTION PHARMACOKINETICS

Zosyn (Piperacillin + tazobactam) Piperacillin kills bacteria by •
Restores activity against resistant inhibiting the synthesis of
organisms: E. Coli, Bacteroides spp., bacterial cell walls. It binds
H. Influenzae, P. Aeruginosa, Staph. preferentially to specific •
Aureus penicillin-binding proteins
(PBPs) located inside
bacterial cell walls.
Augmentin (Amoxicillin + Amoxicillin binds to •
clavulanate) penicillin-binding proteins
Active against those organisms that within the bacterial cell wall •
have become resistant to and inhibits bacterial cell wall
amoxacillin. Includes penicillin- synthesis. Clavulanic acid is a
resistant Staph. aureus. β-lactam, structurally related
to penicillin, that may •
inactivate certain β-
lactamase enzymes.
Adults and children weighing over 40
kg (88 lbs): Infuse 3.375 grams
intravenously (by IV) every 6 hours.
If you caught pneumonia from being in
a hospital, you will need a higher dose
of 4.5 grams, and your provider may
prescribe another antibiotic at the
same time.
Each tablet of AUGMENTIN contains
0.63 mEq potassium.
Amoxicillin and clavulanate potassium
are well absorbed from the
gastrointestinal tract after oral
administration of AUGMENTIN.
Dosing in the fasted or fed state has
minimal effect on the
pharmacokinetics of amoxicillin.
 LICEO DE CAGAYAN UNIVERSITY
Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
COLLEGE OF PHARMACY
MACROLIDES
• Macrolides represent a large family of protein synthesis inhibitors of great clinical interest due to
their applicability to human medicine. Macrolides are composed of a macrocyclic lactone of
different ring sizes, to which one or more deoxy‐sugar or amino sugar residues are attached.
• First discovered in the 1950s, when scientists isolated erythromycin from the soil bacterium
Streptomyces erythraeus. In the 1970s and 1980s synthetic derivatives of erythromycin, including
clarithromycin and azithromycin, were developed.

MECHANISM OF ACTIONS

• Bind to 50S ribosomal subunit and inhibit protein synthesis by blocking the polypeptide exit
tunnel, which prevents peptide chain prolongation.

RESISTANCE

• Methylation of the 50S ribosome (altered target affinity)

• Altered cell wall permeability (reduced expression of porins, or expression of porins with modified
selectivity)

MACROLIDES (DRUGS)

DRUGS
Erythromycin Clarithromycin Azithromycin
• Rarely used to treat infections due • Commonly used for Use to treat the following:
to increasing resistance & more respiratory tract & • Respiratory tract infections
favorable alternatives, including sinus infections • Skin infections (SSTIs)
clarithromycin & azithromycin • STIs (Chlamydia, GC,
• It is most commonly used (off- • Treatment of infections chancroid)
label) as a prokinetic to treat by Helicobacter pylori, • Traveler’s diarrhea
gastroparesis (to stimulate Hemophilus influenzae, Mycobacterium avium complex
stomach motility) Mycobacterium avium (MAC)
• Preoperative bowel preparation complex (MAC) .
(oral administration of
erythromycin base). The base
form of erythromycin is “relatively
poorly absorbed” (20-50%) from
the GI tract and is given orally
along with neomycin or
kanamycin as a pre-op bowel
preparation (to cleanse the bowel
of bacteria before surgery).
• An alternative drug for
Legionnaire’s diseas.
 LICEO DE CAGAYAN UNIVERSITY
Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
COLLEGE OF PHARMACY
PHARMACOKINETICS
Erythromycin Clarithromycin Azithromycin
• orally absorbed as stearate or estolate Twice a day dosing; acid Once a day dosing; needs to be
salt, CSF penetration poor, biliary and stable with better GI given 2 hrs before or after a
fecal excretion. absorption than meal.
• Acid labile & absorption of salt erythromycin.
formulations from the GI tract is
variable.
• Needs to be given 2 hrs before or after
a meal. The non-salt (base) form is not
well absorbed when taken orally, and
is used for sterilizing the gut before
surgery.

SIDE EFFECTS

• Mild GI upset
• Hypersensitivity
• Cholestatic jaundice (caused by the estolate salt of erythromycin)
• Inhibition of Cytochrome P-450 (drug interactions) but not with azithromycin
 LICEO DE CAGAYAN UNIVERSITY
Rodolfo N. Pelaez Boulevard, Kauswagan, Cagayan de Oro City
COLLEGE OF PHARMACY
REFERENCES:

Foye’s Principles of Medicinal Chemistry (PDF)

• Khanna, N. R., & Gerriets, V. (2021). Beta Lactamase Inhibitors. PubMed; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK557592/#:~:text=Beta%2Dlactamase%20inhibitors%2
0are%20drugs
• Worthington, R. J., & Melander, C. (2013). Overcoming Resistance to β-Lactam Antibiotics. The
Journal of Organic Chemistry, 78(9), 4207–4213. https://doi.org/10.1021/jo400236f
• Macrolides [TUSOM | Pharmwiki]. (n.d.). Tmedweb.tulane.edu.
https://tmedweb.tulane.edu/pharmwiki/doku.php/macrolides
• Betalactam_pharm [TUSOM | Pharmwiki]. (n.d.). Tmedweb.tulane.edu.
https://tmedweb.tulane.edu/pharmwiki/doku.php/betalactam_pharm
• Perry, C. M., & Markham, A. (1999). Piperacillin/tazobactam: an updated review of its use in the
treatment of bacterial infections. Drugs, 57(5), 805–843. https://doi.org/10.2165/00003495-
199957050-00017
• Evans, J., Hannoodee, M., & Wittler, M. (2020). Amoxicillin Clavulanate. PubMed; StatPearls
Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538164/