BscNR20 T5 Antibiotics

7/22/2022
Objectives
By the end of this lecture, students should know:

Antibiotics a) Basic terminologies applied in the area of
antibiotics.
b) Antibiotic target sites.
c) Classes of antibiotics, mechanisms of action and
their spectrum of activity.
d) Mechanisms of antibiotic resistance.
e) Human factors that promote antibiotic resistance.
f) How antibiotic resistance can be tackled.
g) Importance of antibiotic stewardship programme.
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Terminologies
 Antibiotic combination: Combination of antibiotics
 Antibiotic: A chemical that kills or reduces the quantity that may be used to:
of bacteria.
(i) broaden the antibacterial spectrum for empirical
 Antibacterial spectrum: Range of activity of an
therapy or the treatment of polymicrobial infections.
antimicrobial against bacteria.
- Broad-spectrum: antibacterial drug inhibits a variety
(ii) prevent the emergence of resistant bacteria during
of gram-positive and gram-negative bacteria.
therapy,
- Narrow-spectrum: antibacterial drug is active only
against a limited variety of bacteria.
(iii) achieve a synergistic killing effect.
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Sites of antibiotic activity

Sites of antibiotic activity
Target FOUR sites:

1) Disruption of cell wall
2) Inhibition of protein synthesis
3) Inhibition of nucleic acid synthesis
4) Antimetabolite
Murray et al. pg 204, 5th ed, medical microbiology
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1. Inhibition of cell wall synthesis

Contains 4 groups:
a) β-lactam antibiotics:
- penicillins
- cephalosporins
- cephamycins
- carbapenems
- monobactams
Mechanisms of action and resistance - β-lactamase inhibitors
b) Glycopeptides: Vancomycin and teichoplanin
c) Polypeptide: Bacitracin
d) Antimycobacterial drugs:
- Isoniazid
- Ethambutol
- Cycloserine
- Ethionamide
Mechanism of action
a) β-Lactam Antibiotics
 Peptidogylcan layer is the major component of
bacterial cell wall.
 Its basic structure consists of:
- chains of 10 to 65 disaccharide residues consisting of
alternating molecules of NAG and NAM acid.
- These chains are cross-linked with peptide bridges.

β-lactam ring
- the building of chains and cross-links is facilitated by

enzymes such as: transpeptidases, transglycosylases
and carboxypeptidases.
Resistance Mechanisms to β-Lactam

 These enzymes are also called penicillin-binding Antibiotics
proteins (PBPs).
Three mechanisms
 β-Lactam ring binds to the PBPs and inhibits the
formation of cross-links between peptidoglycan chain. I. Prevention of the interaction between the antibiotic and
the target PBP.
 This activates autolysins that degrade the cell wall,
resulting in bacterial cell death. II. Modification of the binding of the antibiotic to the PBP.
III. Hydrolysis of the antibiotic by β-lactamases.

 β-lactam antibiotics are bactericidal agents.
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(i) Prevention of the interaction between the (ii) Modification of the binding of the antibiotic to
antibiotic and the target PBP the PBP
This can be mediated by:

 Only seen in Gram-negative bacteria (particularly
Pseudomonas species). a) An overproduction of PBP (a rare occurrence).
 Why? They have an outer membrane that overlies the b) Acquisation of a new PBP. E.g. methicillin resistance in
peptidoglycan layer. Staphylococcus aureus.
 Penetration of β-lactam antibiotics into gram-negative rods c) Modification of an existing PBP through:
requires transit through pores in the outer membrane. - Recombination. E.g. Penicillin resistance in
Streptococcus pneumoniae. OR
 Changes in the proteins (porins) that form the walls of the
- A point mutation. E.g. Penicillin resistance in
pores can alter the size of charge of these channels and
Enterococcus faecium.
result in the exclusion of the antibiotic.
Situation 1: Pencillins
(iii) Hydrolysis of the antibiotic β-lactamases
•They inhibit multiple
 Bacteria can produce enzyme β-lactamases that inactivate bacterial enzymes,
the β-lactam antibiotics. namely, penicillin-binding
proteins (PBPs), that
 More 200 β-lactamases have been described.
catalyze the last steps of
 Some are specific. E.g peptidoglycan synthesis.
i) penicillinases inactivate penicillins
(ii) cephalosporinases inactivate cephalosporins •They confer bactericidal
(iii) carbapenemases inactivate carbapenems. activity against Gram-
 Some inactivate a broad range of β-lactam antibiotics. positive bacteria.
•S1: Assignment: Describe

the spectrum of activity.
Situation 2: Cephalosporins
 Cephalosporins are derivatives of the fermentation
products of Cephalosporium acremonium.
 They contain a 7-aminocephalosporanic acid
nucleus, which consists of a β-lactam ring fused to a
dihydrothiazine ring.
 Various substitutions at positions 3 and 7 alter their
antibacterial activities and pharmacokinetic
properties.
 Addition of a methoxy group at position 7 of the β-
lactam ring makes them broad spectrum.
- As a result, they are highly resistant to hydrolysis
by a variety of class A β-lactamases, including many
ESBLs.
 S2: Assignment: Describe the spectrum of activity.
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Situation 3: Other β-lactam antibiotics c) Carbapenems

• They have the widest spectrum of antibacterial activity of the
a) Monobactams are drugs with a monocyclic β-lactam ring, currently available antibiotics.
binds primarily to PBP 3 of Gram-negative aerobes, thereby
• Structurally, they differ from other β-lactams in having a
disrupting bacterial cell wall synthesis.
hydroxyethyl side chain in the trans configuration at position 6
- Their spectrum of activity is limited to aerobic gram-negative
and possessing a carbon atom in place of a sulfur or oxygen
rods.
atom in the bicyclic nucleus.
- S3: Assignment: Describe the spectrum of activity.
• The unique stereochemistry of the hydroxyethyl side chain
b) β-lactamase inhibitors (clavulanic acid, sulbactam and
confers stability against most β-lactamases.
tazobactam).
- It inhibits penicillinases from staphylococci and many group 2 • MOA: Carbapenems bind with high affinity to PBP 2 and then to
β-lactamases from Gram-negative bacteria. These agents act PBPs 1a and 1b of Gram-negative bacteria, causing spherical
primarily as a “suicide inhibitor” by forming an irreversible acyl cell formation and lysis.
enzyme complex with the β-lactamase, leading to loss of • Available for clinical use: Doripenem, ertapenem, imipenem and
activity of the enzyme. meropenem.
- S4: Assignment: Describe the spectrum of activity. • S5: Assignment: Describe the spectrum of activity and
resistance.
b) Glycopeptides
 Resistance is achieved by modification of the D-Ala-D-
 Vancomycin, teicoplanin, telavancin and dalbavancin Ala binding site of the peptidoglycan building block in
which the terminal D-Ala is replaced by D-lactate.
Vancomycin
 This results in the loss of a critical hydrogen bond that
 Originally obtained from Streptomyces orientalis.
facilitates high affinity binding of vancomycin to its
 Disrupts the cell wall peptidoglycan synthesis: target and loss of activity
- interacts with D-alanine-D-alanine termini of the
 Clinical usage: Bloodstream infections and
pentapeptide side chains, which interferes with the
endocarditis.
formation of the bridges between the peptidoglycan
chains.  S6: Assignment 6: Describe the spectrum of activity;
and mode of action and clinical statuses of teicoplanin,
 Only active against gram-positive bacteria.
telavancin and daptomycin.
 Resistance is promoted by genes vanA and vanB.
c) Polypeptides d) Isoniazid, Ethionamide, Ethambutol and

Cycloserine
Bactracin
 Isolated from Bacillus licheniformis.  They are used for the treatment of mycobacterial
 Inhibits cell wall synthesis by interfering with dephosphorylation infections.
and the recycling of the lipid carrier responsible for moving the
(i) Isoniazid:
peptidoglycan precursors through the cytoplasmic membrane to
the cell wall.  Affects synthesis of mycolic acid.
 It may also damage the bacterial cell membrane and inhibit  Isoniazid is a prodrug that is activated by KatG
ribonucleic acid (RNA) transcription. (mycobacterial catalase-peroxidase). The activated form
 Active against gram-positive bacteria. of isoniazid forms a covalent complex with an acyl
 Widely used topically to treat skin infections caused by carrier protein (AcpM) and KasA, a beta-ketoacyl carrier
Staphylococcus and group A Streptococcus. protein synthetase, which blocks mycolic acid synthesis
and kills the cell.
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 Resistance to isoniazid is associated with:

a) mutations resulting in overexpression of inhA ,
(ii) Ethambutol
which encodes an NADH-dependent acyl carrier  Ethambutol inhibits mycobacterial arabinosyl
protein reductase; transferases, which are encoded by the embCAB
b) mutation or deletion of the katG gene;
operon.
 Arabinosyl transferases are involved in the
c) promoter mutations resulting in overexpression of
ahpC , a putative virulence gene involved in polymerization reaction of arabinoglycan, an essential
protection of the cell from oxidative stress; and component of the mycobacterial cell wall.
 Resistance to ethambutol is due to mutations resulting
d) mutations in kasA .
in overexpression of emb gene products or within the
embB structural gene.
Summary
(iii)Ethionamide: Chemically related to isoniazid and
similarly blocks the synthesis of mycolic acids.
(iv) Cycloserine: Inhibits two enzymes, d-alanine-d-
alanine synthalase and alanine racemase, which
catalyze cell wall synthesis.
 Resistance to the four antibiotics results from (i)
reduced drug uptake into the cell wall or (ii) alteration of
the target site.
Spicer, pg 196
2. Inhibition of Protein Synthesis

(i) Aminoglycoside
 They include:
- Streptomycin
- Neomycin
Isolated from Streptomyces species
- Kanamycin
- Tobramycin
- Gentamicin
- Sisomicin Isolated from Micromonospora
 Mode of action: Bind irreversibly to the 30S ribosomal

protein subunit.
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 They are bactericidal.

 Mostly used in the treatment of many gram-negative
rods (e.g. Enterobacteriaceae, Pseudomonas and
 Effects: Acinetobacter).
a) leads to production of aberrant proteins as the  Resistance develops in one of the following ways:
result of misreading of the mRNA (i) mutation of the ribosomal binding site.
b) Interruption of protein synthesis by causing (ii) decreased uptake of the antibiotic into the bacterial
premature release of the ribosome from mRNA cell.
leading to death. (iii) increased expulsion of the antibiotic from the cell.
c) Interference with the initiation complex of peptide (iv) enzymatic modification of the antibiotic.
formation - Most common.
- done by action of phosphotransferases,
adenyltransferases and acetyltransferases on the
amino and hydroxyl groups of the antibiotic.
Consists of amino sugars linked through glycosidic bonds to an

aminocyclitol ring
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(ii) Oxazolidinones (iii) Tetracyclines
 Narrow spectrum.  Broad-spectrum and bacteriostatic.

 Linezolid in market.  Examples: Tetracycline, doxycycline, minocycline.
 Blocks initiation of protein synthesis by interfering with the  Tetracyclines are active against many gram-positive and
formation of the initiation complex consisting of tRNA fMet, gram negative bacteria, including certain anaerobes,
mRNA, initiation factors and the ribosome. Chlamydia, Mycoplasma and Rickettsia.
 Linezolid binds to a unique site on the 23S rRNA in the 50S  Mode of action:
ribosomal subunit, which distorts the binding site for - Binds reversibly to the 30S ribosomal subunits.
tRNAfmet, thus inhibiting formation of the 70S initiation - Hence blocking the binding of aminoacyl-transfer RNA
complex, thus preventing initiation of mRNA translation. (tRNA) to the 30S ribosome-mRNA complex. This prevents
 Assignment: Discuss resistance and clinical spectrum. addition of amino acids to the growing peptide.
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Basic structure of tetracyclines

Resistance mechanisms
 Impaired influx or increased efflux by an active

transport protein pump.
 Ribosome protection due to production of proteins that

interfere with tetracycline binding to the ribosome.
 Enzymatic inactivation.
(iv) Chloramphenicol
 Broad-spectrum.
 Mode of action: Binds reversibly to the peptidyl
transferase component of the 50S ribosomal subunit,
thus blocking peptide elongation.
 Resistance: Through plasmid-encoded
chloramphenicol acetyltransferase, which catalyzes the
acetylation of the 3-hydroxly group of chloramphenicol.
The product is incapable of binding to the 50S subunit.
(v) Macrolides
 Mode of action:
 Protoype drug: Erythromycin. - Reversible binding to the 23S rRNA of the 50S
ribosomal subunit, which blocks polypeptide elongation.
 It was derived from
 Resistance:
Streptomyces erythreus.
- Reduced permeability of the cell membrane or active
 Broad-spectrum and
efflux.
bacteriostatic.
- Inactivation of the macrolides by enzymes (esterase,
The basic structure  Is active against susceptible phosphorylases, glycosidase).
is a microcyclic strains of gram-positive. - Modification of the ribosomal binding site by
lactone ring bound  Semisynthetic derivatives of chromosomal mutation or by a macrolide-inducible or
by two sugars, erythromycin: constitutive methylase.
desosamine and - clarithromycin and azithromycin
cladinose
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(vi) Clindamycin
 In the family of
lincosamide.
 Derivative of lincomycin,
which originated from
Streptomyces lincolnensis.
Summary
 Mode of action:
- Like erythromycin, blocks protein elongation by
binding to the 50S ribosome.
- It inhibits peptidyl transferase by interfering with the
binding of the amino acid-acyl-tRNA complex.
 Resistance:
- Mutation of the ribosomal receptor site
- Modification of the receptor by a constitutively
expressed methylase
- Enzymatic inactivation of clindamycin
Spicer, pg 196
3. Inhibition of Nucleic Acid Synthesis

(i) Fluoroquinolones
 The important quinolones are synthetic fluorinated analogs of
nalidixic acid (see figure 46-3).  DNA gyrase - A subunit
 They are active against a variety of gram-positive and gram- is the primary target in
negative bacteria. gram-negative bacteria.
Mode of action  Topoisomerase type IV
 Inhibit bacterial DNA topoisomerase type II (DNA gyrase) or is the primary target in
topoisomerase type IV which are required for DNA replication,
gram-positive bacteria.
recombination and repair.
 DNA gyrase prevents the relaxation of positively supercoiled DNA
that is required for normal transcription and replication.
 Inhibition of topoisomerase IV interferes with separation of
replicated chromosomal DNA into the respective daughter cells
during cell division.
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(ii) Rifampin
Resistance mechanism
 Rifampin is a semisynthetic derivative of rifamycin, an antibiotic
 It is mediated by chromosomal mutations in the
produced by Streptomyces mediterranei.
structural genes for DNA gyrase and topoisomerase
Mode of action:
type IV. - Rifampin binds to the β subunit of bacterial DNA-dependent
 Other mechanisms include: RNA polymerase and thereby inhibits RNA synthesis.
- decreased drug uptake caused by mutations in the  Bactericidal for Mycobacterium tuberculosis.
membrane permeability genes  Very active against aerobic gram-positive bacteria.
- Overexpression of efflux pumps that actively emilinate Resistance mechanism:
the drug.  In gram-positive bacteria, it results from a mutation in the
 Each mechanism is primarily chromosome mediated. chromosomal gene that encodes for the β subunit of RNA
polymerase.
 In gram-negative, it is a result of decreased uptake of
hydrophobic antibiotic.
(iii) Metronidazole 4. Antimetabolites

(i) Sulfonamides
 Active against anaerobic bacteria.
 Mode of action:
- reduction of its nitro group by bacterial nitroreductase
thereby producing cytotoxic compounds that disrupt the  The basic formulas of the
host DNA sulfonamides and their
structural similarityt o p -
 Resistance mechanisms:
aminobenzoic acid (PABA)
- decreased uptake of the antibiotic OR
- from elimination of the cytotoxic compounds before
they can interact with host DNA.
Mode of action:  Active against a broad range of gram-positive and gram-

 Some bacteria do not use negative bacteria
exogenous folate.  Combination of a sulfonamide with an inhibitor of
dihydrofolate reductase (trimethoprim or pyrimethamine)
 They must synthesize folate
provides synergistic activity because of sequential inhibition
from PABA (see pathway on of folate synthesis ( Figure 46–2 )
the right side).
 Sulfonamide resistance may occur as a result of mutations
 The pathway is thus essential that:
for production of purines and (i) cause overproduction of PABA
nucleic acid synthesis (ii) cause production of a folic acid-synthesizing enzyme that
 As structural analogs of PABA, has low affinity for sulfonamides, or
sulfonamides inhibit (iii) impair permeability to the sulfonamide.
dihydropteroate synthase and  Clinical usage: The fixed-drug combination of trimethoprim-
folate production sulfamethoxazole is the drug of choice for treatment of
various infections
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(ii) Trimethoprim and trimethoprim-

 Resistance to trimethoprim can result from
sulfamethoxazole mixtures (i) reduced cell permeability
 Trimethoprim, a trimethoxybenzylpyrimidine, selectively (ii) overproduction of dihydrofolate reductase, or
inhibits bacterial dihydrofolic acid reductase, which (iii) production of an altered reductase with reduced
converts dihydrofolic acid to tetrahydrofolic acid, a step drug binding.
leading to the synthesis of purines and ultimately to DNA  Clinical Usage:
( Figure 46–2 ). - A combination of trimethoprim-sulfamethoxazole is
 Trimethoprim or pyrimethamine in combination with a effective treatment for a wide variety of infections
sulfonamide blocks sequential steps in folate synthesis, - Pyrimethamine and sulfadiazine have been used for
resulting in marked enhancement (synergism) of the treatment of leishmaniasis and toxoplasmosis
activity of both drugs. - In falciparum malaria, the combination of
 The combination often is bactericidal, compared with the pyrimethamine with sulfadoxine (Fansidar) is used.
bacteriostatic activity of a sulfonamide alone.
Human factors that promote antibiotic How resistance can be tackled

resistance  People can help tackle resistance by:
 Misuse and overuse of antibiotics. a) using antibiotics only when prescribed by a
- taken by people with viral infection like colds and flu. doctor;
- patients not finishing entire antibiotic course. b) completing the full prescription, even if they feel
- when they are given as growth promoters in animals. better;
- when they are used to prevent diseases in healthy animals. c) never sharing antibiotics with others or using
leftover prescriptions.
 Bacteria do spread between environment, people and animals.
Hence, the following encourage spread of antibiotic resistance:
- poor infection control  Health workers and pharmacists can help tackle resistance
by:
- inadequate sanitary conditions
a) enhancing infection prevention and control;
- inappropriate food-handling
b) only prescribing and dispensing antibiotics when
 Wide spread usage of antibiotic containing pesticides and other they are truly needed;
household products. c) prescribing and dispensing the right antibiotic(s) to
 Absence of new antibiotics being discovered. treat the illness.
 Government s and policymakers can help tackle resistance by: Antimicrobial stewardship Programme
a) strengthening resistance tracking and laboratory capacity;
 The optimal selection, dosage, and duration of
b) regulating and promoting appropriate use of medicines; antimicrobial treatment that results in the best clinical
c) educating the public about antibiotics and antibiotic outcome for the treatment or prevention of infection, with
resistance
minimal toxicity to the patient and minimal impact on
subsequent resistance.
 Policymakers and industry can help tackle resistance by:
 Goals:
a) fostering innovation and research and development of
a) to work with health care practitioners to help each
new antibiotics;
b) promoting cooperation and information sharing among all
patient receive the most appropriate antimicrobial with
stakeholders the correct dose and duration.
c) promoting usage of alternatives to antibiotics e.g. usage b) to prevent antimicrobial overuse, misuse, and abuse.
of non-essential target inhibitors c) to minimize the development of resistance.
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Strategies of implementing antimicrobial

stewardship program
Further Reading
1. Educational programs, using standardized order
sometimes forms, and requiring a) Jawetz, Melnick & Adelberg’s Medical
incorporating feedback justification for the use Microbiology, 26th Edition, page 60
of information of particular agents b) Lansing M. Prescott, Microbiology, 5th Edition,
obtained from 3. Concurrent monitoring Chapter 35, page 806 - 819.
antimicrobial audits of antimicrobial usage
2. Administrative with intervention when
measures, such as misuse is identified
limiting the 4. Computer-assisted
antimicrobials in a selection of antibiotics
hospital’s formulary,

BscNR20 T5 Antibiotics

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7/22/2022

By the end of this lecture, students should know:

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Sites of antibiotic activity

Target FOUR sites:

2) Inhibition of protein synthesis

3) Inhibition of nucleic acid synthesis

Murray et al. pg 204, 5th ed, medical microbiology

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1. Inhibition of cell wall synthesis

- These chains are cross-linked with peptide bridges.

- the building of chains and cross-links is facilitated by

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Resistance Mechanisms to β-Lactam

III. Hydrolysis of the antibiotic by β-lactamases.

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This can be mediated by:

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•S1: Assignment: Describe

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Situation 3: Other β-lactam antibiotics c) Carbapenems

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c) Polypeptides d) Isoniazid, Ethionamide, Ethambutol and

 Resistance to isoniazid is associated with:

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2. Inhibition of Protein Synthesis

 Mode of action: Bind irreversibly to the 30S ribosomal

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 They are bactericidal.

Consists of amino sugars linked through glycosidic bonds to an

(ii) Oxazolidinones (iii) Tetracyclines

 Narrow spectrum.  Broad-spectrum and bacteriostatic.

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Basic structure of tetracyclines

 Impaired influx or increased efflux by an active

 Ribosome protection due to production of proteins that

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3. Inhibition of Nucleic Acid Synthesis

(iii) Metronidazole 4. Antimetabolites

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Mode of action:  Active against a broad range of gram-positive and gram-

(ii) Trimethoprim and trimethoprim-

Human factors that promote antibiotic How resistance can be tackled

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Strategies of implementing antimicrobial

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