1 Antimicrobial Therapy Chemotherapy: any treatment of patient with chemicals to treat a condition. –Now word associated with cancer treatment –Our focus is on antimicrobial agents “Antibiotics”: antibiotics, semi-synthetic, or synthetic –Antibiotics: natural products made by microbes, effective against other microbes –Semi-synthetic antibiotics: use natural antibiotic as base, but modified chemically; most of our new “antibiotics” –Synthetic: made chemically in their entirety

2 Spectrum Some antibiotics are considered “broad spectrum” –By definition, these are effective against many types of bacteria, both Gram negative and Gram positive –Broad spectrum antibiotics can sometimes cause problems because of damage to normal microbiota of host Microbiota (not plants!) –“Superinfection” may result from this situation Overgrowth of “normal” microbes that cause disease Increased susceptibility to newly acquired microbes

3 Selective Toxicity: the key to antibiotic therapy 3 concentration ranges: ineffective, effective, and toxic. A drug needs to have a wide effective (therapeutic) range. Selective toxicity is the ability of the drug to harm the target without harming the host. Bacteria have many targets that are biologically different from us that the drugs can hit. As the target becomes more like us, there are fewer and fewer drugs that are selectively toxic: fungi, protozoa, worms, viruses, cancer.

4 Selective Toxicity and side effects Drugs may fail to be selectively toxic and interfere with mammalian biochemistry. They may cause allergies. They may destroy too many normal bacteria.

5 Actions of antimicrobials Drugs work against microbes by these basic mechanisms: –Inhibition of cell wall synthesis Causes bacterium to commit suicide, but only during growth when cells are cutting their own PG. –Disruption of membrane function Often toxic to humans because we have membranes too, cause leakage of vital molecules. –Inhibition of protein synthesis – many antibiotics Bind to ribosomal RNAs, proteins. –Inhibition of nucleic acid synthesis Attack transcription, DNA unwinding enzymes –Act as anti-metabolites – competitive inhibitors, inhibit function of enzymes, usually bacteriostatic.

6 Ideal Antibiotic Good drug properties (e.g. soluble in body fluids) Selectively toxic, obviously Easily administered Non-allergenic Stable in vivo, slowly broken down and excreted Difficult for microbe to become resistant to. Long shelf life (chemically stable) low $

7 Measurement of Efficacy Disk diffusion assay –Paper disks with antibiotic applied to lawn in Petri dish –Zone of inhibition indicates susceptibility to drug Broth dilution test to measure MIC –Minimum inhibitory concentration –Drug is diluted in broth which is inoculated –Clear broth indicates that bacteria did not grow or were killed. –That concentration of drug that first inhibits: MIC

8 Why bacteria might be resistant They are that way naturally –Gram negative cell wall prevents antibiotics from entering the cell and reaching their targets. –Some bacteria have no cell wall, so no target. The way they infect –Some bacteria enter cells where antibiotic conc is low. Some bacteria are mutated –Mutation changes the target for the antibiotic. Bacteria acquire new genes: –The new genes provide ways to foil the drugs

9 Mechanisms of drug resistance (How do they do it?) Alteration of target: active site of enzyme changes, change in ribosome means drug no longer binds. Antibiotic either can’t get in or can’t stay in: transport protein changes, drug no longer enters; drug that does enter is actively pumped out. Enzymatic destruction of drug: penicillinases (beta lactamases) “End around” inhibitor: bacteria learns to use new metabolic pathway, drug no longer effective.

10 Attack by penicillinase Bacterial enzymes (beta lactamases = penicillinases) destroy this ring. Penicillins no longer work. Some penicillins were created to resist these enzymes.

11 Human behavior and antibiotic resistance Bacteria once under control are making a comeback due to antibiotic resistance: –S. aureus, Enterococcus, M. tuberculosis, et al. Human behavior: –Most diseases caused by viruses, non-cellular, not treatable with antibiotics (but Doctor, do something) –Full time course needed; last bacteria left are the most resistant, if they aren’t killed, they become “normal”; don’t stop regimen because you feel better. Social behavior –resistance in homeless/poor –growth stimulants in agriculture

12 Fighting antibiotic resistance Use all drug at sufficiently high concentration –Don’t allow the least sensitive bacteria to survive Drugs in combination –Odds of mutating to resist 2 drugs: 1 in 10 6 x 10 6 –Synergism: e.g. amoxicillin and clavulanic acid Limit antibiotic use –>50% of infections are viral; not affected by antibiotics –Constant exposure breeds resistance New drugs

13 Penicillins amoxicillinAmoxil ampicillinPenbritin co-amoxiclavAugmentin flucloxacillinFloxapen phenoxymethylpenicillinPenicillin V Cephalosporins cefaclorDistaclor cefalexinCeporex, Keflex cefotaximeClaforan vancomycinVancocin bacitracin Common antibiotics inhibiting cell wall synthesis Other

Common antibiotics inhibiting protein synthesis 14 Macrolides clarithromycinKlaricid erythromycinErymax, Erythrocin, Erythroped azithromycinZithromax Tetracyclines doxycyclineVibramycin oxytetracyclineOxymycin, Oxytetramix tetracycline Aminoglycosides gentamicinCidomycin neomycinNivemycin Others chloramphenicol clindamycinDalacin C

Common antibiotics: nucleic acid targets 15 Quinolones ciprofloxacinCiproxin levofloxacinLevaquin Others metronidazoleFlagyl rifampicin Disruption of membrane function Others polymyxin B Anti-fungal drugs (several)

Antimetabolites 16 trimethoprimMonotrim sulfamethoxazole Combinations Amoxacillin and clavulanic acidAugmentin Trimethoprim and sulfamethoxazoleBactrim Neomycin, bacitracin & polymyxinNeosporin