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Title: Definitions


1
Definitions
  • Bacteremia Presence of bacteria in the blood
  • Under normal circumstances, the blood is a
    sterile environment

2
Systemic Inflammatory Response Syndrome (SIRS)
  • An inflammatory response, to a wide variety of
    clinical insults, characterized by two or more of
    the following
  • Temperature greater than 38 oC (100.4 oF)
  • Heart rate greater than 90 beats per min
  • Respiratory rate greater than 20 breaths per min
  • White blood cell count greater than 12,000/mL

3
Sepsis
Sepsis is a systemic inflammatory response to a
documented infection In addition to preceding
criteria, at least one of the following must be
present Alteration in mental state Hypoxemia
(lower pressure of oxygen in blood) Elevated
plasma lactate
4
Lipopolysaccharide is Part of the Outer Membrane
of Gram Negative Bacteria
5
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7
  • Bacterial lipopolysaccharides are toxic to
    animals. When injected in small amounts LPS or
    endotoxin activates several host responses that
    lead to fever, inflammation and shock.

8
  • Endotoxins may play a role in infection by any
    Gram-negative bacterium. The toxic component of
    endotoxin (LPS) is Lipid A. The O-specific
    polysaccharide may provide for adherence or
    resistance to phagocytosis, in the same manner as
    fimbriae and capsules.

9
  • The O polysaccharide (also referred to as the O
    antigen) also accounts for multiple antigenic
    types (serotypes) among Gram-negative bacterial
    pathogens.
  • Thus, E. coli O157 (the Jack-in-the-Box and Stock
    Pavillion E. coli) is 157 of the different
    antigenic types of E. coli and may be identified
    on this basis.

10
Allergic Responses to Antibiotics
  • Uticaria A skin rash involving dark red itchy
    bumps.

11
Allergic Responses
  • Anaphylaxis A severe, life-threatening allergic
    response, having many potential manifestations,
    including loss of consciousness, labored
    breathing, swelling of the tongue, low blood
    pressure, etc.

12
Shock
  • Shock is characterized by low blood pressure
    (hypotension) and tachycardia
  • Septic shock is a result of the infection itself
    (bacteremia, sepsis).
  • Anaphylactic shock is an allergic response to a
    foreign agent (antibiotic, bee sting, etc.)

13
Vancomycin
Carbohydrate
Peptide Linkages
Vancomycin is called a glycopeptide, meaning
that it is a cyclic peptide, with sugar residues
attached to it.
14
Discovery
Vancomycin was discovered in a soil sample sent
to the pharmaceutical company Eli Lilly by a
missionary in Borneo in the 1950s.
15
Vancomycin Mechanism of Action
  • Bacterial Cell Wall Synthesis (review)
  • http//student.ccbcmd.edu/courses/bio141/lecguide/
    unit2/control/ppgsynanim.html

Penicillin Mechanism of Action (review) http//stu
dent.ccbcmd.edu/courses/bio141/lecguide/unit2/cont
rol/penres.html
  • http//student.ccbcmd.edu/courses/bio141/lecguide/
    unit2/control/vanres.html
  • Link

16
Mechanism of Action of Vancomycin
Vancomycin binds to the D-alanyl-D-alanine
dipeptide on the peptide side chain of newly
synthesized peptidoglycan subunits, preventing
them from being incorporated into the cell wall
by penicillin-binding proteins (PBPs). In many
vancomycin-resistant strains of enterococci, the
D-alanyl-D-alanine dipeptide is replaced with
D-alanyl-D-lactate, which is not recognized by
vancomycin. Thus, the peptidoglycan subunit is
appropriately incorporated into the cell wall.
17
Vancomycin Uses
  • Vancomycin is used to treat aerobic Gram
    bacteria, including MRSA and strains of
    penicillin-resistant Streptococcus pneumoniae
  • Vancomycin is most often administered
    intravenously
  • Vancomycin can also be used to treat anearobic
    Gram bacteria, including Clostridium difficile
    (in the case of a GI infection, Vancomycin can be
    administered orally).
  • Vancomycin cannot be used to treat Gram
    bacteria, since the large size of the vancomycin
    molecule prohibits its passing of the outer
    membrane.

18
Vancomycin Resistance
  • Some Enterococci have developed resistance to
    vancomycin (Enterococcus faecium and Enterococcus
    faecalis).
  • These bacteria are called Vancomycin Resistant
    Enterococci (VRE)

19
  • The mechanism of resistance involves the
    transformation of the D-Ala-D-Ala linkage in the
    peptide side chain into D-Ala-D-Lac (i.e.
    replacement of the amide NH by an O)
  • This terminal linkage is still recognized by the
    essential PBPs (so the cell wall can still be
    constructed), but is not recognized by vancomycin
    (thus resulting in resistance).

20
Antimicrobial Activity of Vancomycin
Gram-positive bacteria Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes. Viridans group streptococci, Streptococcus pneumoniae, Some enterococci.
Gram-negative bacteria
Anaerobic bacteria Clostridium spp. Other Gram-positive anaerobes.
Atypical bacteria
21
Daptomycin
Lipophilic Tail
  • Daptomycin is called a lipopeptide antibiotic
  • Approved for use in 2003
  • Lipid portion inserts into the bacterial
    cytoplasmic membrane where it forms an
    ion-conducting channel.
  • Marketed under the trade name Cubicin

22
Step 1 Daptomycin binds to the cytoplasmic
membrane in a calcium-dependent manner Step 2
Daptomycin oligomerizes, disrupting the
membrane Step 3 The release of intracellular
ions and rapid death
Link
23
Uses of Daptomycin (Cubicin)
  • Daptomycin is active against many aerobic
    Gram-positive bacteria
  • Includes activity against MRSA,
    penicillin-resistant Streptococcus pneumoniae,
    and some vancomycin-resistant Enterococci (VRE)
  • Daptomycin is not active against Gram negative
    strains, since it cannot penetrate the outer
    membrane.

24
  • Primarily been used to treat skin and soft tissue
    infections (complicated skin and skin structure
    infections, including MRSA).
  • Also approved for S. aureus bloodstream
    infections (bacteremia), including those with
    right-sided infective endocarditis
  • Poor activity in the lung, thus not used for
    pneumonia

25
  • Cubicin (Daptomycin) is administered
    intravenously.
  • It is not orally bioavailable.

26
Antimicrobial Activity of Daptomycin
Gram-positive bacteria Streptococcus pyogenes, Viridans group streptococci, Streptococcus pneumoniae, Staphylococci, Enterococci.
Gram-negative bacteria
Anaerobic bacteria Some Clostridium spp.
Atypical
27
Rifamycins
  • Rifampin is the oldest and most widely used of
    the rifamycins
  • Rifampin is also the most potent inducer of the
    cytochrome P450 system

28
The Rifamycins
Rifampicin (Rifampin)
Rifabutin (Mycobutin)
Rifaximin (Xifaxan (US), Spiraxin (EU))
Rifapentine (Priftin)
29
  • Therefore, Rifabutin (brand name Mycobutin) is
    favored over rifampin in individuals who are
    simultaneously being treated for tuberculosis and
    HIV infection, since it will not result in
    oxidation of the antiviral drugs the patient is
    taking.

30
  • Rifaximin is a poorly absorbed rifamycin that is
    used for treatment of travelers diarrhea.

31
Mechanism of Action of Rifampin
  • Rifampin inhibits transcription by inactivating
    bacterial RNA polymerase

32
  • Resistance develops relatively easily, and can
    result from one of a number of single mutations
    in the baqcterial gene that encodes RNA
    polymerase.
  • Therefore, Rifampin is rarely used as monotherapy
    (i.e. not used as a single agent) but usually
    combined with other antibiotics

33
Uses of Rifampin
  • Used, in combination with other drugs, to treat
    Mycobacterium tuberculosis
  • Used to treat some Staphylococcal infections.
  • Rifampin and the other rifamycins are orally
    bioavailable.

34
The Rifamycins include Rifampin, Rifabutin,
Rifapentine, and Rifaximin, all of which can be
administered orally. Rifampin can also be
administered parenterally.
Gram-positive bacteria Staphylococci
Gram-negative bacteria Haemophilus influenzae, Neisseria meningitidis
Anaerobic bacteria
Mycobacteria Mycobacterium tuberculosis, Mycobacterium avium complex, Mycobacteriumleprae.
35
Aminoglycosides
The structure of the aminoglycoside amikacin.
Features of aminoglycosides include amino sugars
bound by glycosidic linkages to a relatively
conserved six-membered ring that itself contains
amino group substituents.
36
Aminoglycoside Mechanism of Action
  • Aminoglycosides bind to the 30S subunit of the
    bacterial ribosome, thereby inhibiting bacterial
    protein synthesis (translation)
  • Link
  • LINK
  • Link

37
The ribosome target of aminoglycosides is a
combination of RNA (below) and proteins
38
Uses of Aminoglycoside Antibiotics
  • Unlike vancomycin, the aminoglycosides have
    excellent activity against Gram aerobic
    bacteria
  • Their extensive positive charge enables them to
    bind to and penetrate the negatively charged
    outer membrane and get into the periplasm
  • They are further transported into the cytoplasm
    by a bacterial transport system.

39
  • Bacterial resistance to aminoglycosides occurs
    via one of three mechanisms that prevent the
    normal binding of the antibiotic to its ribosomal
    target
  • Efflux pumps prevent accumulation of the
    aminoglycoside in the cytosol of the bacterium.
  • Modification of the aminoglycoside prevents
    binding to the ribosome.
  • Mutations within the ribosome prevent
    aminoglycoside binding.

40
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41
The Aminoglycosides include Streptomycin,
Gentamicin, Tobramycin, and Amikacin (all
parenteral), as well as Neomycin (topical, oral).
42
Aminoglycosides
Streptomycin
Streptomycin was the first aminoglycoside to be
discovered (1944) and it still valuable (in
combination with other antibacterial agents) in
the treatment of multidrug resistant tuberculosis
(although not a first line drug for tuberculosis)
43
Aminoglycosides
Gentamicin
  • Gentamicin is most commonly used of the
    aminoglycosides
  • Active against aerobic Gram-negative infections
    (and sometimes Gram positive)
  • Can be used synergistically, together with a cell
    wall targeting agent (e.g. a penicillin)
  • Available in parenteral, opthalmic, and topical
    formulations

44
Aminoglycosides
Tobramycin
  • Tobramycin has better activity against
    Pseudomonas aeruginosa than does gentamicin
  • Tobramycin may be given either intramuscularly or
    intravenously
  • It is also administered by inhaler, particularly
    useful for individuals with cystic fibrosis
    (frequently contract P. aeruginosa infections)

45
Amikacin
  • Amikacin has the broadest antimicrobial spectrum
    of the aminoglycosides
  • It is more resistant to aminoglycoside-inactivatin
    g enzymes than the other aminoglycosides
  • It is often used in hospitals where gentamicin-
    and tobramycin-resistant microorganisms are
    prevalent

46
Neomycin
  • Neomycin is widely used for topical
    administration
  • Like other aminoglycosides, it is not absorbed
    well orally, and is used to prepare the bowel for
    surgery.

47
The Aminoglycosides include Streptomycin,
Gentamicin, Tobramycin, and Amikacin (all
parenteral), as well as Neomycin (oral).
Gram-positive bacteria Used synergistically against some Staphylococci, Streptococci, Enterococci, and Listeria monocytogenes
Gram-negative bacteria Haemophilus influenzae, Enterobacteiaceae, Pseudomonas aeruginosa
Anaerobic bacteria
Atypical bacteria
Mycobacteria Mycobacterium tuberculosis, Mycobacterium avium complex.
48
Macrolides and Ketolides
The structures of erythromycin and telithromycin
Circled substituents and distinguish
telithromycin from the macrolides.
49
Chemical Definitions
Ester Linkage
Cladinose Sugar
  • Macrolide macrocyclic lactone (cyclic ester)
  • Macrolide antibiotics usually have ring sizes of
    14, 15, or 16 atoms

50
Substituent allows telithromycin to bind to a
second site on the bacterial ribosome.
51
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52
Mechanism of Action of Macrolide Antibiotics
  • Macrolides bind tightly to the 50S subunit of the
    bacterial ribosome, thus blocking the exit of the
    newly synthesized peptide
  • Thus, they are interfering with bacterial
    translation
  • Link
  • Link

53
Uses of Macrolide Antibiotics
  • Active against a broad range of bacteria
  • Effective against some stphylococci and
    streptococci, but not usually used for MRSA or
    penicillin-resistant streptococci
  • Most aerobic Gram- bacteria are resistant
  • Active against many atypical bacteria and some
    mycobacteria and spirochetes

54
The macrolide group consists of Erythromycin,
Clarithromycin, and Azithromycin (all oral, with
erythromycin and azithromycin also being
available parenterally).
Clariithromycin
Erythromycin
55
Erythromycin reactions under acidic conditions
56
Clarithromycin substitutes a methoxy group for
the hydroxy and improves acid stability
Methoxy group
Hydroxy group
Clariithromycin (14 membered ring)
Erythromycin (14 membered ring)
57
Insertion of N into the ring
Azithromycin (15 membered ring)
Link
LInk
58
The macrolide group consists of Erythromycin,
Clarithromycin, and Azithromycin (all oral, with
erythromycin and azithromycin also being
available parenterally).
Gram-positive bacteria Some Streptococcus pyogenes. Some viridans streptococci, Some Streptococcus pneumoniae. Some Staphylococcus aureus.
Gram-negative bacteria Neiseria spp. Some Haemophilus influenzae. Bordetella pertussis
Anaerobic bacteria
Atypical bacteria Chlamydia spp. Mycoplasma spp. Legionella pneumophila, Some Rickettsia spp.
Mycobacteria Mycobacterium avium complex, Mycobacterium leprae.
Spirochetes Treponema pallidum, Borrelia burgdorferi.
59
Uses of Telithromycin (a ketolide)
  • Telithromycin is approved for use against
    bacterial respiratory infections
  • Active against most strains of Streptococcus
    pneumoniae, including penicillin- and
    macrolide-resistant strains
  • Also active against more strains of Staphylococci
  • Only available in oral formulation

60
Cladinose sugar replaced by ketone
Telithromycin A ketolide (14 membered ring)
61
The related ketolide class consists of
Telithromycin (oral).
Gram-positive bacteria Streptococcus pyogenes, Streptococcus pneumoniae, Some Staphylococcus aureus
Gram-negative bacteria Some Haemophilus influenzae, Bordetella pertussis
Anaerobic bacteria
Atypical bacteria Chlamydia spp. Mycoplasma spp. Legionella pneumophila
62
The Tetracycline Antibiotics
The structure of tetracycline
63
Tetracycline Antibiotics
Tetracycline
Tigecycline
Doxycycline
64
Mechanism of Action of the Tetracycline
Antibiotics
  • The tetracyclines bind to the 30S subunit of the
    bacterial ribosome and prevent binding by tRNA
    molecules loaded with amino acids.
  • LINK

65
Uses of the Tetracycline Antibiotics
  • Main use is against atypical bacteria, including
    rickettsia, chlamydia, and mycoplasmas
  • Also active against some aerobic Gram-positive
    pathogens and some aerobic Gram-negative bacteria

66
The Tetracycline Class of Antibiotics consists of
Doxycycline and Tigecycline (parenteral) as well
as Tetracycline, Doxycycline and Minocycline
(oral)
Gram-positive bacteria Some Streptococcus pneumoniae
Gram-negative bacteria Haemophilus influenzae, Neisseria meningitidis
Anaerobic bacteria Some Clostridia spp. Borrelia burgdorferi, Treponema pallidum
Atypical bacteria Rickettsia spp. Chlamydia spp.
67
Tigecycline
68
The antimicrobial activity of Tigecycline
(parenteral)
Gram-positive bacteria Streptococcus pyogenes. Viridans group streptococci, Streptococcus pneumoniae, Staphylococci, Enterococci, Listeria monocytogenes
Gram-negative bacteria Haemophilus influenzae, Neisseria spp. Enterobacteriaceae
Anaerobic bacteria Bacteroides fragilis, Many other anaerobes
Atypical bacteria Mycoplasma spp.
69
Chloramphenicol
70
Mechanism of Action of Chloroamphenicol
  • Binds to the 50S subunit of the bacterial
    ribosome, where it blocks binding of tRNA

71
Uses of Chloramphenicol
  • Severe toxicity limits utility
  • The most serious side effect of chloramphenicol
    treatment is aplastic anaemia (a condition where
    bone marrow does not produce sufficient new cells
    to replenish blood cells)
  • This effect is rare and is generally fatal there
    is no treatment and there is no way of predicting
    who may or may not get this side effect.
  • The effect usually occurs weeks or months after
    chloramphenicol treatment has been stopped.

72
Uses of Chloramphenicol
  • However, despite its toxicity, chloramphenicol
    has a wide spectrum of activity, that includes
    many aerobic Gram-positive, Gram-negative,
    anaerobic, and atypical bacteria

73
The Antimicrobial Activity of Chloramphenicol
Gram-positive bacteria Streptococcus pyogenes, Viridans group streptococci. Some Streptococcus pneumoniae
Gram-negative bacteria Haemophilus influenzae, Neisseria spp. Salmonella spp. Shigella spp.
Anaerobic bacteria Bacteroides fragilis. Some Clostridia spp. Other anaerobic Gram-positive and Gram negative bacteria
Atypical bacteria Rickettsia spp. Chlamydia trachomatis, Mycoplasma spp.
74
Clindamycin
75
Mechanism of Action of Clindamycin
  • Clindamycin binds to the 50S subunit of the
    ribosome to inhibit protein synthesis

76
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77
Uses of Clindamycin
  • Clindamycin is a member of the lincosamide series
    of antibiotics
  • Main utility is in treatment of Gram-positive
    bacteria and anaerobic bacteria
  • Active against Staphylococcus, including some
    strains of MRSA
  • Not useful against Gram-negative bacteria

78
Toxicity of Clindamycin
  • Clindamycin kills many components of the
    gastrointestinal flora, leaving only Clostridium
    difficile
  • This can result in overgrowth by C. difficile,
    which is resistant

79
The Antimicrobial Activity of Clindamycin (both
oral and parenteral)
Gram-positive bacteria Some Streptococcus pyogenes, Some viridans group streptococci. Some Streptococcus pneumoniae, Some Staphylococcus aureus
Gram-negative bacteria
Anaerobic bacteria Some Bacteroides fragilis, Some Clostridium spp. Most other anaerobes.
Atypical bacteria
80
Streptogramins
81
Mechanism of Action of Streptogramins
  • Dalfopristin inhibits the early phase of protein
    synthesis in the bacterial ribosome and
    quinupristin inhibits the late phase of protein
    synthesis. The combination of the two components
    acts synergistically and is more effective in
    vitro than each component alone.
  • Link

82
Uses of the Streptogramins
  • Have activity against Gram positive aerobic
    bacteria
  • Including MRSA, penicillin-resistant
    Streptococcus pneumoniae and some VRE (active
    against vancomycin resistant Enterococcus
    faecelis, but not Enterococcus faecium)
  • The Quinupristin/Dalfopristin mixture is marketed
    as Synercid

83
The Antimicrobial Activity of Quinupristin/Dalfopr
istin (parenteral)
Gram-positive bacteria Streptococcus pyogenes, Viridans group streptococci, Streptococcus pneumoniae, Staphylococcus aureus, Some enterococci.
Gram-negative bacteria
Anaerobic bacteria
Atypical bacteria
84
The Oxazolidinones
The structure of Linezolide
85
  • Binds to the 50S subunit and prevents association
    of this unit with the 30S subunit.

86
Mechanism of Action of the Oxazolidinones
  • Binds to the 50S subunit and prevents association
    of this unit with the 30S subunit.
  • LINK

87
Uses of the Oxazolidinones
  • Has excellent activity against most aerobic
    Gram-positive bacteria, including MRSA and VRE.
  • Only oxazolidonone on the market now is
    Linezolid, which is both oral and intravenous.

88
The Antimicrobial Activity of Linezolid (both
oral and parenteral)
Gram-positive bacteria Streptococcus pyogenes. Viridans group streptococci, Streptococcus pneumoniae, Staphylococci, Enterococci.
Gram-negative bacteria
Anaerobic bacteria
Atypical bacteria
89
The Sulfa Drugs
  • LINK
  • Most commonly used sulfa drug is a mixture of the
    sulfa drug Sulfamethoxazole and Trimethoprim
  • These two drugs work in synergy, with the
    combination being superior to either drug alone.

Sulfamethoxazole
Trimethoprim
90
  • This combination is known as co-trimoxazole,
    TMP-sulfa, or TMP-SMX

91
Mechanism of Activity of Sulfa Drugs
  • Trimethoprim-sulfamethoxazole works by preventing
    the synthesis of tetrahydrofolate (THF), an
    essential cofactor for the metabolic pathways
    that generate deoxynucleotides, the building
    blocks of DNA.

92
Tetrahydrofolic Acid Biosynthetic Pathway
  • In the first step of the pathway, the
    sulfonamides are mistaken for the natural
    substrate, p-aminobenzoic acid (PABA) and the
    drug acts as a competitive inhibitor of this
    enzyme
  • In a later step, the trimethoprim acts as a
    structural analog of dihydrofolate and therefore
    inhibits dihydrofolate reductase

93
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96
The Target of Trimethoprim is Dihydrofolate
Reductase (DHFR)
97
Inhibitors of Dihydrofolate Reductase (DHFR)
98
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100
Structural Resemblance of Sulfamethoxazole and
p-Aminobenzoic Acid
Sulfamethoxazole
p-Aminobenzoic Acid
101
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102
Another sulfa drug is Dapsone, which is used to
treat Mycobacterium leprae
Dapsone
103
Structural Comparison of Two Sulfa Drugs
104
The Antimicrobial Activity of the Sulfa Drugs
Gram-positive bacteria Some Sreptococcus pneumoniae, Some Staphylococci, Listeria monocytogenes
Gram-negative bacteria Some Haemophilus influenzae, Some Enterobacteriaceae
Anaerobic bacteria
Atypical bacteria
Mycobacteria (Dapsone) Mycobacterium leprae
105
The Fluoroquinolones
106
Fluoroquinolones
107
Mechanism of Action Quinolones
  • Quinolone antibiotics inhibit bacterial DNA
    gyrase (Gram negative bacteria) or Topoisomerase
    IV (Gram positive bacteria)
  • Link
  • LINK
  • LINK

108
Uses of the Quinolone Antibiotics
  • Urinary Tract Infections fluoroquinolones are
    more effective than trimethoprim-sulfamethoxazole
  • Prostatitis
  • Respiratory tract infections
  • Gastrointestinal and Abdominal Infections

109
Antimicrobial Activity of the Quinolones (oral)
Gram-positive bacteria Some Staphylococcus aureus, Streptococcus pyogenes, Virdans group streptococci, Streptococcus pneumoniae
Gram-negative bacteria Neisseria spp. Haemophilus influenzae Many Enterobacteriaceae, Some Pseudomonas aeruginosa
Anaerobic bacteria Some clostridia spp, Some Bacteroides spp.
Atypical bacteria Chlamydia and Chlamydophilia, Mycoplasma pneumoniae, Legionella spp
Mycobacteria Mycobacterium tuberculosis, Mycobacterium avium complex, Mycobacterium leprae
110
Metronidazole (Flagyl)
Metronidazole is used in the treatment of
infections caused by anaerobic bacteria
111
Metronidazole Mechanism of Action
Metronidazole is a prodrug. It is converted in
anaerobic organisms by the redox enzyme
pyruvate-ferredoxin oxidoreductase. The nitro
group of metronidazole is chemically reduced by
ferredoxin (or a ferredoxin-linked metabolic
process) and the products are responsible for
disrupting the DNA helical structure, thus
inhibiting nucleic acid synthesis.
112
Mechanism of Action of Metronidazole
  • Metronidazole is selectively taken up by
    anaerobic bacteria and sensitive protozoal
    organisms because of the ability of these
    organisms to reduce metronidazole to its active
    form intracellularly.

113
  • Systemic metronidazole is indicated for the
    treatment of
  • Vaginitis due to Trichomonas vaginalis
    (protozoal) infection in both symptomatic
    patients as well as their asymptomatic sexual
    contacts
  • Pelvic inflammatory disease in conjunction with
    other antibiotics such as ofloxacin,
    levofloxacin, or ceftriaxone
  • Protozoal infections due to Entamoeba histolytica
    (Amoebic dysentery or Hepatic abscesses), and
    Giardia lamblia (Giardiasis) should be treated
    alone or in conjunction with iodoquinol or
    diloxanide furoate
  • Anaerobic bacterial infections such as
    Bacteroides fragilis, spp, Fusobacterium spp,
    Clostridium spp, Peptostreptococcus spp,
    Prevotella spp, or any other anaerobes in
    intraabdominal abscess, peritonitis, empyema,
    pneumonia, aspiration pneumonia, lung abscess,
    diabetic foot ulcer, meningitis and brain
    abscess, bone and joint infections, septicemia,
    endometritis, tubo-ovarian abscess, or
    endocarditis
  • Pseudomembranous colitis due to Clostridium
    difficile
  • Helicobacter pylori eradication therapy, as part
    of a multi-drug regimen in peptic ulcer disease
  • Prophylaxis for those undergoing potentially
    contaminated colorectal surgery and may be
    combined with neomycin

114
Antimicrobial Activity of Metronidazole (both
oral and intravenous)
Gram-positive bacteria
Gram-negative bacteria
Anaerobic bacteria Bacteroides fragilis, Clostridium spp. Most other anaerobes
Atypical bacteria
115
Antimicobacterial Agents
  • Mycobacterial infections are very slow
    progressing
  • Many antibiotics have poor activity against slow
    growing infections
  • Mycobacteria must be treated for a long time, and
    therefore, may readily develop resistance to a
    single antibiotic
  • Typically, several antibiotic agents are used
    simultaneously

116
Antimycobacterial Agents
Pyrazinamide
Rifampin
Ethambutol
117
Mycobacterial Infections
http//www.nature.com/nrmicro/animation/imp_animat
ion/index.html http//web.uct.ac.za/depts/mmi/lst
eyn/cellwall.html
118
Mycolic Acids provide protection
  • Mycolic acids are long fatty acids found in the
    cell envelope of the mycolata taxon, a group of
    bacteria that includes Mycobacterium
    tuberculosis, the causative agent of the disease
    tuberculosis. They form the major component of
    the cell wall of mycolata species.
  • The presence of mycolic acids gives M.
    tuberculosis many characteristics that defy
    medical treatment. They lend the organism
    increased resistance to chemical damage and
    dehydration, and prevent the effective activity
    of hydrophobic antibiotics. In addition, the
    mycolic acids allow the bacterium to grow readily
    inside macrophages, effectively hiding it from
    the host's immune system.

119
Mycobacterium Cell Wall
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121
Mechanism of Action of Anti-Mycobacterial
Antibiotics
  • Rifampin is an inhibitor of RNA polymerase

122
  • Isoniazide inhibits the synthesis of mycolic acid

123
Mechanism of Action of Isoniazid
isoniazid
NADH
Isoniazid is a produg, that is activated by a
mycobacterial peroxidase, called KatG to form a
reactive free radical, which, in turn, reacts
with NADH to form a covalent adduct. The
reactive (isoniazid-derived) species is probably
an acyl radical (shown)
124
Mechanism of Action of Isoniazid
This isoniazid-NADP adduct then forms a complex
with bacterial enoyl reductase (InhA),an enzyme
responsible for reducing double bonds during
fatty acid synthesis
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  • Pyrazinoic acid inhibits the enzyme fatty acid
    synthetase I (FAS I), which is required by the
    bacterium to synthesise fatty acids.

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  • Ethambutol disrupts the formation of the cell
    envelope by interfering with the enzyme that
    forms the arabinogalactan polysaccharide (called
    arabinogalactan transferase)

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Arabinogalactan
D-Galactose
  • Arabinogalactan is a biopolymer consisting of
    arabinose and galactose monosaccharides

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Arabinogalactan-mycolic acid adduct
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Targets of First Line anti-TB Drugs
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Overview of anti-mycobacterial drugs
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Antimicrobial Resistance
  • LINK

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Assigned Reading
  • Antibiotic Basics for Clinicians, by Alan R.
    Hauser, pp. 3399
  • Kirkpatrick Peter Raja Aarti LaBonte Jason
    Lebbos John Daptomycin. Nature reviews. Drug
    discovery (2003), 2(12), 943-4.
  • Ammerlaan, H. S. M. Bonten, M. J. M.
    Daptomycin graduation day. Clinical
    Microbiology and Infection (2006), 12(Suppl.
    8), 22-28.
  • Baltz, Richard H. Miao, Vivian Wrigley, Stephen
    K. Natural products to drugs Daptomycin and
    related lipopeptide antibiotics. Natural
    Product Reports (2005), 22(6), 717-741. pp.
    717-722, 725-726.
  • Baltz Richard H Daptomycin mechanisms of action
    and resistance, and biosynthetic engineering.
    Current opinion in chemical biology (2009),
    13(2), 144-51. Journal code 9811312.
  • Clay Kimberly D Hanson John S Pope Scott D
    Rissmiller Richard W Purdum Preston P 3rd Banks
    Peter M Brief communication severe
    hepatotoxicity of telithromycin three case
    reports and literature review. Annals of
    internal medicine (2006), 144(6), 415-20.
  • Zeitlinger, Markus Wagner, Claudia Christina
    Heinisch, Birgit. Ketolides - the modern
    relatives of macrolides the pharmacokinetic
    perspective. Clinical Pharmacokinetics
    (2009), 48(1), 23-38.
  • Vicens, Quentin Westhof, Eric. RNA as a drug
    target The case of aminoglycosides.
    ChemBioChem (2003), 4(10), 1018-1023.
  • Wilson, Daniel N. Nierhaus, Knud H. The
    oxazolidinone class of drugs find their
    orientation on the ribosome. Molecular Cell
    (2007), 26(4), 460-462.
  • Marchese, A. Schito, G. C. The oxazolidinones
    as a new family of antimicrobial agent.
    Clinical Microbiology and Infection (2001),
    7(Suppl. 4), 66-74.
  • Asaka, Toshifumi Manaka, Akira Sugiyama,
    Hiroyuki. Recent developments in macrolide
    antimicrobial research. Current Topics in
    Medicinal Chemistry (Sharjah, United Arab
    Emirates) (2003), 3(9), 961-989. READ ONLY
    PP. 961-966 AND 981-983
  • Zhanel, George G. Homenuik, Kristen Nichol,
    Kim Noreddin, Ayman Vercaigne, Lavern Embil,
    John Gin, Alfred Karlowsky, James A. Hoban,
    Daryl J. The glycylcyclines a comparative
    review with the tetracyclines. Drugs (2004),
    64(1), 63-88. Read pp. 64-72

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Homework Questions
  1. To which site on the ribosome do the
    aminoglycoside antibiotics bind?
  2. A high level of aminoglycoside resistance is
    known to result from the A1408G mutation in
    bacterial ribosomes. A potential solution would
    be to design aminoglycosides that can bind more
    tightly to this mutation. Why cant this be
    achieved?
  3. Discuss the advantages and the disadvantages of
    using RNA as a drug target.
  4. The activity o f daptomycin is highly dependent
    on which alkaline earth metal? What is the
    function of this metal in the mechanism of action
    (MOA) of daptomycin?
  5. At which ribosomal site do the oxazolidinones
    bind? What accounts for their side effects in
    patients undertaking prolonged treatment with
    these drugs?
  6. Why is azithromycin currently considered one of
    the best of the macrolides?
  7. Explain how tetracyclines gain access to the
    cytoplasm of Gram-negative bacteria.
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