ANTIMICROBIAL DRUGS

Laboratory of Microbiology
Medical Faculty Brawijaya University
 LEARNING OBJECTIVE

1. DESCRIBE THE PRINCIPLE OF SELECTIVE TOXICITY

2. DEFINE THE FOLLOWING TERMS: SYNTHETIC DRUGS,
SEMI SYNTHETIC DRUGS, ANTIBIOTICS,

SPECTRUM ACTIVITY, SUPERINFECTION

3. IDENTIFY FIVE MODES OF ACTION OF ANTIMICROBIAL

DRUGS

4. DESCRIBE THE DRUGS USED FOR ANTIBACTERIAL,

ANTIFUNGAL, AND ANTIVIRAL
 Antimicrobial drugs the class of medication used in
chemotherapy
the treatment of infectious diseases
using chemical substances

Unlike disinfectants often act within the host, therefore,

effects on the cells and tissues of the host are important

the ideal antimicrobial drug kills the harmful microorganism

without damaging the host (SELECTIVE TOXICITY)
SELECTIVE TOXICITY

- is ability of the drug to differentiate between host cell

and microbe
- based on the difference of cell structure & function between
host with microbe, for instance: cell wall, ribosome, or cell
membrane component

Antibacterial high selective toxicity

Antifungal, antiparasite, antivirus low select. toxicity
 CONDITION of GOOD ANTIMICROBIAL DRUGS

- has a good selective toxicity

- do not generate hypersensitivity reaction
- has a good solubility and penetrating effect into tissue
- slow in metabolism and excretion
- slow in development of resistant microorganism strain
- do not damage normal microbiota of the host
- inexpensive
 ORIGIN OF ANTIMICROBIAL DRUGS

1. Drugs that have been synthetized by chemical procedures

in the laboratory synthetic drugs
ex. Sulfonamide, Quinolone
2. Drugs produced by bacteria and fungi antibiotics
ex. Penicillin, Chloramphenicol, Tetracycline
3. Semi synthetic drugs:
using natural formula and modified in laboratory, aimed
to: - improving in pharmacokinetic effects
- increasing spectrum activity
- improving of drugs stability
- decreasing of drugs toxicity
ex. Amoxicillin, Methicillin, Cefotaxim, Amantadine
 ANTIMICROBIAL ACTIVITY

--CIDAL meaning kills microbes

--STATIC meaning inhibits the growth of microbes
- the hosts own defenses, such as phagocytes
and antibody, usually destroy the microbes

NARROW SPECTRUM
- affect a part of microbes (mostly), either Gram positive or
Gram negative bacteria, ex. : ERYTHROMYCIN, PENICILLIN G
BROAD SPECTRUM
- affect a broad range of Gram positive and Gram negative
bacteria, ex. : AMOXICILLIN, TETRACYCLINE, SULFONAMIDE
BROAD SPECTRUM Antimicrobial

Advantage : because the identity of pathogen is not always

immediately known, the drug would seem
to have an advantage in treating a disease
by saving valuable time

Disadvantage: many normal microbiota of the host are

destroyed by the drug

SUPERINFECTION : a term of overgrowth of microorg which is

not sensitive to bacterial antibiotics
ex. overgrowth of C.albicans due to oral taking
of antibiotics causing diarrhoea
THE ACTION of ANTIMICROBIAL DRUG

Inhibiting the synthesis of cell wall

Injury to the plasma membrane
Inhibiting the synthesis of protein
Inhibiting the synthesis of nucleic acid
Inhibiting the synthesis of essential metabolites
The inhibition of the cell wall synthesis
The cell wall of a bacterium consists of a macromolecule
called peptidoglycan
Drugs can affect the cell wall synthesis in several ways:
- to interfere peptidoglycan synthesis at early stage or
synthesis of linear strand of ( in cytoplasm)
ex. Vancomycin, Bacitracin
- preventing peptidoglycan synthesis at late stage
(the final cross linking of the peptidoglycan)
ex. Penicillin, Cephalosporine
- pursuing peptidoglycan synthesis by competitive
effect to sugar and lipid as a component of the
peptidoglycan, ex. Fosfomycin
-Lactam antibiotics
(Penicillins, Cephalosporine, Carbapenem, Aztreonam)
Attach to receptor called PBPs (Penicillin-binding Proteins)
inhibiting transpeptidase on peptidoglycan synthesis
activating the lytic enzyme (exist in the cell wall)
PBPs : - 3 to 6 types representing transpeptidation enz
- under chromosomal control

Affect only actively growing cells

The damage of cell wall:

- in ordinary tonicity the cell undergoes lysis
- in hypertonicity may still in living cells form
(Gram positive bacteria Protoplast
Gram negative bacteria Spheroplast)
-Lactamase
an enzyme which will hidrolyze the -lactam ring of
Penicillins (penicillinase) and Cephalosporine
produced by many species of Gram-positive and
Gramnegative
plasmid mediated, also chromosomally mediated
ESBLs (extended-spectrum -lactamases):
-lactamase which has an ability to hidrolyze
Cefotaxim, Ceftazidime, and Aztreonam
Clavulanic acid, Sulbactam, Tazobactam
have a high affinity for and irreversibly bind some
-lactamase (-lactamase inhibitors)
protect simultaneously present Penicillins
(Ampicillin, Amoxicillin, Ticarcillin)
Penicillins
1. Natural Penicillin from Penicillium notatum
broken by Penicillinase (-lactamase)
has narrow spectrum
ex. Penicillin-G (damaged by stomach acid)
Penicillin-V (acid stable)

2. Semisynthetic Penicillin
acid stable , ex. Ampicillin, Amoxicillin
resistant to penicillinase:
ex. Methicillin, Cloxacillin, Oxacillin
has broad spectrum
ex. Ampicillin, Amoxicillin
Cephalosporines
from Cephalosporium acremonium Cephalosporine C
resistant to penicillinase (but sensitive to a separate group
of -lactamase)
semisynthetic cephalosporine:
- first generation: Cephalexin, Cephradine, Cefazolin
- second generation: Cefamandole, Cefoxitin
- third generation: Cefoperazone, Cefotaxime,
Ceftriaxon
- fourth generation: Cefepime

Each new generation tends to be more effective against Gram-

negatives
 O S CH3
R C NH CH CH C
CH3

O =C N CH COOH Penicillin

O S
R1 C NH
O
O=C N C- CH2 O C R2

COOH Cephalosporine
( = -lactam ring,
R = alkyl-molecule)
Injury to the plasma membrane

Certain antimicrobial can affect plasma membrane by :

- changes in the permeability (by attaching to the
phospholipids of the membrane)
ex. Polymyxin B
- combine with sterols in plasma membrane
ex. Amphotericin B, Azole derivatives (antifungal drugs)

bacterial plasma membrane generally lack sterols

animal cells do contain cholesterol (selective toxicity?)
To inhibit of protein synthesis

Protein synthesis is a common feature of all cells,

whether procaryotic or eucaryotic
Fortunately, eucaryotic cells have 80S ribosome,
while procaryotic cells have 70S ribosome
Alert : mitochondria also contain 70S ribosome !
ex. Chloramphenicol, Tetracycline, Erythromycin

(selective toxicity?)
To inhibit of nucleic acid synthesis

Interfere with the processes of DNA replication

ex. Quinolone derivatives
Interfere with the transcription processes
ex. Rifampicin
(how about selective toxicity?)
Inhibiting the synthesis of essential metabolites
A particular enzymatic activity of microorganism can be
competitively inhibited by a substance (antimetabolite) that
closely resembles the normal substance for the enzyme
ex. Sulfanilamide with PABA

NH2 NH2

Sulfanilamide PABA

COOH
SO2NH

- PABA is the substrate for an enzymatic reaction leading to the

synthesis of folic acid (coenzyme for the synthesis of purine and
pyrimidine)
 PTERIDINE + PABA

Sulfonamide

DIHYDROPTEROIC ACID

DIHYDROFOLIC ACID
Trimethoprim

TETRAHYDROFOLIC ACID

FOLIC ACID

The combination of Sulfonamide and Trimethoprim results

the sequential inhibition
Humans do not produce folic acid from PABA
(selective toxicity?)
 COMMONLY USED ANTIMICROBIAL DRUGS

1. ANTIBACTERIAL
Penicillins bactericide
- Ampicillin, Amoxicillin Gram-pos & Gram-neg
- Methicillin, Oxacillin Gram-positives producing
penicillinase
Tetracycline, Oxytetracycline, Doxycycline
- broad spectrum & bacteriostatic
- Gram-pos, Gram-neg, Rickettsiae, Chlamydiae
Chloramphenicol
- bacteriostatic
- broad spectrum, drug of choice for S.typhi
Erythromycin
- narrow spectrum & bacteriostatic
- is used also in order to hypersensitive reaction to Penicillins
 Gentamycin, Netilmicin, Amikacin
- bactericide
- broad spectrum (include Pseudomonas aeruginosa)
Sulfonamid (or with Trimethoprim)
- bacteriostatic
- broad spectrum
Quinolone (ex. Ciprofloxacin, Norfloxacin)
- bactericide
- broad spectrum
Nalidixic acid
- urinary antiseptic
Linezolid
- for Gram-positives, MRSA (Methicillin Resistant
Staphylococcus aureus)
2. ANTIMYCOBACTERIAL
ANTITUBERCULOSIS
need drugs combination, because its easy to be
resistant
Isoniazid, Rifampin, Pyrazinamide main therapy
Ethambutol, Streptomycin additional therapy

ANTILEPRAE
DDS (4,4 diamino diphenyl sulfone)
Rifampicin
3. ANTIFUNGAL
Amphotericin B
- treatment for systemic mycosis
AZOLE derivatives
- Clotrimazole, Miconazole
treatment for superficial mycosis
- Ketoconazole, Fluconazole, Itraconazole
for systemic & subcutaneous mycosis,
nails candidiasis (onychomycosis)
- less toxic compared to Amphotericin
Griseofulvin, Nystatin
- for superficial mycosis
4. ANTIVIRAL
Nucleotida Analogs
- inhibit the synthesis of DNA/RNA

GUANINE ANALOGs :
- ACYCLOVIR treatment for Herpesvirus
- RIBAVIRIN for Rotavirus
- GANCICLOVIR for Cytomegalovirus, Herpesvirus

THYMIDINE ANALOGs :
- TRIFLURIDINE for HERPES which resistant to
ACYCLOVIR
- AZIDOTHYMIDINE (AZT) for HIV
 Enzim Inhibitors
- NEVIRAPINE
inhibit the reverse transcriptase
enzyme on
HIV

Interferon
- cells infected by a virus often produce
interferon, which stimulate host cell to
produce antiviral protein
inhibits further spread of infection
- for Hepatitis virus B & C
- for virus which is cause condyloma

acuminatum
 Resistency of microbe means an effort of
microbe
to be remain to survive

MECHANISM OF RESISTANCE
1. Produce an enzyme to damage drugs
ex. Staphylococcus -lactamase
Gram neg.bacteria
Chloramphenicol- acetyl transferase, fosforilase etc.
2. Alter membrane permeability to antimicrobial
ex. resistant to Tetracycline, Aminoglycosides
3. Alter target site structure of antimicrobial
ex. resistant to Erythromycin alter of receptor
at 50S subunit of ribosome
resistant to Penicillins changing of PBP
4. Making the new way for metabolism
ex. resistant to Sulfonamide
E.coli will be able taking folic acid (not synthesized
by itself)
5. Produce a metabolite substance which is competitive
antagonist to drug
ex. S. aureus increasing of PABA synthesis,
make
it resistant to Sulfonamide
ORIGIN OF RESISTANCE

RESISTANCE

NON GENETICS GENETICS CROSS RESISTANCE

NATURAL ACQUIRED

CHROMOSOMAL EXTRACHROMOSOMAL

THE EFFECT OF INDUCTION - TRANSFORMATION

- TRANSDUCTION
MUTATION - CONJUGATION
- TRANSPOSITION
Non-genetics: for example, Mycobacterium can reside
in cell (Mo) without interrupted by antimicrobial
because they do not perform metabolism
(dormant states)

Cross Resistance: happened in one group of antimicrobial drugs

which much the same to chemical formula,
for example Tetracycline with Doxycycline

Genetics: happened through natural or acquired process

Natural process means the microbe has resistance factor from
the beginning
Acquired process means the microbe has resistence factor:
- by drugs induction, ex. induced by Penicillin make the
microbe loose their cell wall
- from other microbe (by transformation, conjugation,
transduction or transposition mechanism)
OVERCOMING the PROBLEM OF RESISTANCE

The problem of resistance cannot be eliminated but

can be depressed or limited.

1. Maintaining sufficiently level of the drug in

tissues, to inhibit both the original population and
first step mutants (Adequate usage, dosage and
time of regimen)
2. Simultaneusly administering two drugs that do
not give cross-resistance, each of which delays the
emergence of mutants resistant to the other drug
ex. RIFAMPICIN + INH (treatment of tuberculosis)
3. Avoiding exposure of microorganisms to a
particularly valuable drug by limiting its use,
PRACTICAL ISSUES WHICH INDUCE
THE RESISTANCE TO DRUG

1. OVERUSE AND MISUSE of ANTIMICROBIAL USAGE BY

DOCTOR
2. FREE USAGE of ANTIMICROBIAL IN COMMUNITY FOR THE
MEDICATION OF COMMON COLD
3. USING OF ANTIMICROBIAL DRUG IN IMMUNOSUPRESSIVE
PATIENT TO PREVENT SOME INFECTION
4. FAILURE OF PATIENT TO FINISH of THE REGIMEN
MEDICATION
5. LONGTERM USAGE WITH LOW DOSAGE ON MEDICATION
OF ACNE
6. ANTIMICROBIAL USING IN FARM ANIMAL
Antimicrobial drugs may given to farm animal to promote
weigth gain and overcoming infection

to be thougth that toxins of intestinal Clostridium

perfringens may retard the animals growth

The constant presence of antibiotics in animals

puts selective pressure on their normal microbiota,
as well as on their pathogen, will develop drug resistance