1. Antimicrobial Drugs I. Terminology of chemotherapy II. Where antimicrobial drugs come from III. How antimicrobials work IV. Drug resistance V. Interactions between drugs and hosts VI. Selecting the right antimicrobial drug

2. I. Terms When a drug is used to control an infection, the practice is termed antimicrobial chemotherapy Antimicrobial drugs: a class of compounds which inhibit or kill microorganisms. –Antibiotics -- _____________ antimicrobial drugs. –Synthetics -- ______________ antimicrobials. Antibiotics which have been chemically modified are called _________________. –Broad spectrum agents -- –Narrow spectrum agents --

3. Where do antimicrobials come from? Fleming’s discovery of _______________ Fleming’s discovery of _______________ Main sources of useful antibiotics: Streptomyces and Bacillus (____________), Penicillium and Cephalosporium (_________) Main sources of useful antibiotics: Streptomyces and Bacillus (____________), Penicillium and Cephalosporium (_________) Thousands have been discovered; relatively few of these are ___________. Thousands have been discovered; relatively few of these are ___________.

4. How do they work? The main trick if one were to “design” an antibiotic: find something the target pathogen has or does (e.g. a structure or pathway) which the host cell doesn’t. For example, most bacteria have peptidoglycan while eukaryotes don’t so a compound which destroys it or inhibits its production (like penicillin) shouldn’t affect eukaryotes. The main trick if one were to “design” an antibiotic: find something the target pathogen has or does (e.g. a structure or pathway) which the host cell doesn’t. For example, most bacteria have peptidoglycan while eukaryotes don’t so a compound which destroys it or inhibits its production (like penicillin) shouldn’t affect eukaryotes. Toxicity to the host is a major concern Toxicity to the host is a major concern Therapeutic Index -- ratio of a drug’s_________ _________ to its minimum __________________ dose. For example: 16 µg/ml effective dose = ____ 20 µg/ml toxic dose 2 µg/ml = ___ 20 µg/ml versus

5. How do they work (cont.)? Four main approaches: 1) Inhibition of ________ _______ formation -- e.g. penicillin and cephalosporin 2) Inhibition of ________ ________ synthesis -- e.g. sulfonamides 3) Inhibition of ___________ synthesis -- e.g. tetracycline 4) Inhibition of cell ______________ function (less common) e.g. polymixin

6. Cellular targets of antimicrobial drugs PenicillinsPenicillins CephalosporinsCephalosporins VancomycinVancomycin BacitracinBacitracin NovobiocinNovobiocin Nalidixic acidNalidixic acid RifampinRifampin ErythromycinErythromycin ChloramphenicolChloramphenicol TetracyclinesTetracyclines AminoglycosidesAminoglycosides(Streptomycin,Kanamycin,Gentamicin) PolymyxinsPolymyxins

7. Inhibition of cell wall synthesis Penicillin family (“Beta-lactams”)  Penicillin  Amoxicillin  Ampicillin  Carbenicillin  etc. Varies (and can be modified) ß-_______ ring

8. Inhibition of cell wall synthesis (cont.) Cephalosporins  First isolated from Cephalosporium acremonium  Similar to ___________ because also has ß-lactam ring: NH R O COOH R N S (Also can be O) Most have root “cef” in name

9. Nucleic acid synthesis inhibitors ChloroquineTrimethoprim Sulfanilamides (sulfa drugs) Are metabolic ______________ of PABA (para- aminobenzoic acid), necessary for the synthesis of folic acid. Folic acid is then required for the synthesis of ___________ and ______________.

10. Sulfanilamide Sulfanilamide PABA Folic acid Sulfa competes with PABA for the active site on the enzyme which converts PABA to dihydrofolic acid, a precursor of folic acid

11. Protein synthesis inhibitors Tetracyclines -- Semisynthetic drug derived from a natural antibiotic made by Streptomyces. _______________- binding, bacteriostatic, broad spectrum. Erythromycin -- Ribosome-binding antibiotic derived from Streptomyces erythraeus. Also bacterio_________. In antibiotic class known as “_________________” Aminoglycosides (e.g. streptomycin, kanamycin, gentimycin, neomycin). Also derived from Streptomyces, also ribosome-binding but bacteri_________.

12. Structure and derivatives of tetracycline

13. Two New Classes of Antibiotics 1) Fosfomycin -- phosphoric acid used primarily against _____________________ due to enteric bacteria (E. coli, etc.) 2) Synercid (dalfopristin/quinupristin) and Zyvox (linezolid)-- narrow spectrum drugs used primarily against _________________ pathogens such as Staphylococcus, Enterococcus, and Streptococcus.

14. Antimicrobial Drugs I. Terminology of chemotherapy II. Where antimicrobial drugs come from III. How antimicrobials work IV. Drug resistance V. Interactions between drugs and hosts VI. Selecting the right antimicrobial drug

15. Drug resistance mechanisms 1) Enzyme _____________ -- e.g. ß-lactamases

16. Enzyme inactivation (cont.)

17. The arms race: ß-lactamase inhibitors These are not antimicrobial themselves but are prescribed in conjunction with ß-lactam antibiotics to increase their effectiveness. They tend to be expensive.

18. Other drug resistance mechanisms 2) Decreased permeability to the drug  Early penicillins could not pass the __________ _____________ of Gram-negatives 3) Altered ______________ for the drug -- altered cell wall receptors, altered target proteins (e.g. altering 50S ribosomal binding site for erythromycin) 4) Changes in metabolic pathways or enzymes -- e.g. alteration in ________ _________ synthesis 5) Efflux __________ -- antibiotics can be pumped out as fast as they come in. Pseudomonas are particularly famous for this. ä _____________________ is pumped out of cells by plasmid- encoded cytoplasmic membrane proteins

19. The emergence of antibiotic resistance Relationship between antibiotic use and the percentage of bacteria isolated from diarrheal patients resistant to the antibiotic

20. Percentage of reported cases of gonorrhea caused by antibiotic-resistant strains 9000 cases 59000 cases

21. Appearance of antibiotic resistance in several human pathogens since the beginning of antibiotic therapy At Rockingham Memorial Hospital, for example, 88% of Staphylococcus aureus strains isolated in 1999 were resistant to penicillin, ampicillin, and amoxicillin.

22. The Arms Race Continues: S. aureus resistance to a brand-new antibiotic 07/20/2001 Associated Press LONDON – In a frustrating development in the battle against drug- resistant bacteria, scientists report that the first entirely new type of antibiotic in 35 years has been beaten by the staph supergerm little more than a year after being introduced. Researchers at Harvard Medical School describe in the Lancet medical journal this week how an 85-year-old man on dialysis came down with a staph infection in the lining of his intestines that was not vulnerable to the new drug, Zyvox [Linezolid]. It is the first report of staph resistance to the medicine.

23. Antimicrobial Susceptibility Profiles of Selected Aerobes, Rockingham Memorial Hospital, 1999

24. EXPOSURE TO DISINFECTANTS SUCH AS PINE-BASED CLEANERS MAY CONTRIBUTE TO ANTIBIOTIC RESISTANCE Repeated exposure to household cleaners containing pine oil may cause bacteria to develop resistance to some common antibiotics, say researchers from Tufts University School of Medicine in the December 1997 issue of the journal Antimicrobial Agents and Chemotherapy. In the study the researchers repeatedly exposed the bacteria Escherichia coli to a household cleaner containing the disinfectant pine oil or pure pine oil itself in order to isolate pine-oil resistant strains. The resistant strains were then tested against a variety of antibiotics. All pine oil-resistant strains were also multidrug resistant. “To our knowledge, the selection of chromosomal antibiotic resistance, albeit low level, by a disinfectant has not previously been reported for gram-negative bacteria,” say the researchers. “Whether pine oil in products meant for household use could lead to a significant problem of antibiotic resistance is not know. However, it seems possible that additional disinfectants might be capable of selecting for resistance to antibiotics and vice versa.” (M.Moken, L.M. McMurry and S. Levy. 1997. Selection of multiple-antibiotic- resistant mutants of Escherichia coli by using the disinfectant pine oil: roles of the mar and acrAB loci. Antimicrobial Agents and Chemotherapy. 41:2770- 2772.)

25. Host/drug reactions (adverse or “side” effects) Tissue toxicity -- kidneys, liver, heart, skin, nerves, teeth and bones _____________ reactions sensitized on first contact. sensitized on first contact. often due to reaction to a metabolic byproduct often due to reaction to a metabolic byproduct Disruption of normal flora (‘mucking with the microbial ecology of our bodies’) frequent cause of diarrhea frequent cause of diarrhea ____________________ -- secondary infection caused by destruction of normal microflora. ____________________ -- secondary infection caused by destruction of normal microflora. Example: yeast (Candida albicans) infections caused by destruction of vaginal lactobacilli with broad-spectrum antibiotics

26. Picking the right antimicrobial drug 1) Identify (if possible) the agent 2) Determine (if possible) the _______________ of the agent -- e.g.  Kirby-Bauer susceptibility test (will do in lab)  tube dilution test Minimum Inhibitory Concentration = minimum concentration of a drug that visibly __________ ________.

27. Tube dilution test Minimum Inhibitory Concentration (MIC)