1. Antibiotics: Protein Synthesis, Nucleic Acid Synthesis and Metabolism

2. Principles and Definitions Selectivity –Selectivty 8 toxicity 9 Therapeutic index –Toxic dose/ Effective dose Categories of antibiotics –Bactericidal Usually antibiotic of choice –Bacteriostatic Duration of treatment sufficient for host defenses

3. Principles and Definitions Antibiotic susceptibility testing (in vitro) –Minimum inhibitory concentration (MIC) Lowest concentration that results in inhibition of visible growth –Minimum bactericidal concentration (MBC) Lowest concentration that kills 99.9% of the original inoculum

4. Antibiotic Susceptibility Testing 8 4021 Tetracycline (  g/ml) MIC = 2  g/ml Determination of MIC ChlAmp Ery Str Tet Disk Diffusion Test

5. Zone Diameter Standards for Disk Diffusion Tests

6. Principles and Definitions Combination therapy –Prevent emergence of resistant strains –Temporary treatment until diagnosis is made –Antibiotic synergism Penicillins and aminoglycosides CAUTION: Antibiotic antagonism –Penicillins and bacteriostatic antibiotics Antibiotics vs chemotherapeutic agents vs antimicrobials

7. Review of Initiation of Protein Synthesis 30S 1 3 2 GTP 123 Initiation Factors mRNA 3 1 2 GTP 30S Initiation Complex f-met-tRNA Spectinomycin Aminoglycosides 1 2 GDP + Pi 50S 70S Initiation Complex AP

8. Review of Elongation of Protein Synthesis GTP AP Tu GTP Tu GDP Ts Tu + GDP Ts Pi PA Tetracycline AP Erythromycin Fusidic AcidChloramphenicol G GTP G GDP + Pi G GDP AP + GTP

9. Survey of Antibiotics

10. Protein Synthesis Inhibitors Mostly bacteriostatic Selectivity due to differences in prokaryotic and eukaryotic ribosomes Some toxicity - eukaryotic 70S ribosomes

11. Antimicrobials that Bind to the 30S Ribosomal Subunit

12. Aminoglycosides (bactericidal) streptomycin, kanamycin, gentamicin, tobramycin, amikacin, netilmicin, neomycin (topical) Mode of action - The aminoglycosides irreversibly bind to the 16S ribosomal RNA and freeze the 30S initiation complex (30S-mRNA- tRNA) so that no further initiation can occur. They also slow down protein synthesis that has already initiated and induce misreading of the mRNA. By binding to the 16 S r-RNA the aminoglycosides increase the affinity of the A site for t-RNA regardless of the anticodon specificity. May also destabilize bacterial membranes. Spectrum of Activity -Many gram-negative and some gram-positive bacteria; Not useful for anaerobic (oxygen required for uptake of antibiotic) or intracellular bacteria. Resistance - Common Synergy - The aminoglycosides synergize with $ -lactam antibiotics. The $ -lactams inhibit cell wall synthesis and thereby increase the permeability of the aminoglycosides.

13. Tetracyclines (bacteriostatic) tetracycline, minocycline and doxycycline Mode of action - The tetracyclines reversibly bind to the 30S ribosome and inhibit binding of aminoacyl-t-RNA to the acceptor site on the 70S ribosome. Spectrum of activity - Broad spectrum; Useful against intracellular bacteria Resistance - Common Adverse effects - Destruction of normal intestinal flora resulting in increased secondary infections; staining and impairment of the structure of bone and teeth.

14. Spectinomycin (bacteriostatic) Mode of action - Spectinomycin reversibly interferes with m-RNA interaction with the 30S ribosome. It is structurally similar to the aminoglycosides but does not cause misreading of mRNA. Spectrum of activity - Used in the treatment of penicillin-resistant Neisseria gonorrhoeae Resistance - Rare in Neisseria gonorrhoeae

15. Antimicrobials that Bind to the 50S Ribosomal Subunit

16. Chloramphenicol, Lincomycin, Clindamycin (bacteriostatic) Mode of action - These antimicrobials bind to the 50S ribosome and inhibit peptidyl transferase activity. Spectrum of activity - Chloramphenicol - Broad range; Lincomycin and clindamycin - Restricted range Resistance - Common Adverse effects - Chloramphenicol is toxic (bone marrow suppression) but is used in the treatment of bacterial meningitis.

17. Macrolides (bacteriostatic) erythromycin, clarithromycin, azithromycin, spiramycin Mode of action - The macrolides inhibit translocation. Spectrum of activity - Gram-positive bacteria, Mycoplasma, Legionella Resistance - Common

18. Antimicrobials that Interfere with Elongation Factors Selectivity due to differences in prokaryotic and eukaryotic elongation factors

19. Fusidic acid (bacteriostatic) Mode of action - Fusidic acid binds to elongation factor G (EF-G) and inhibits release of EF-G from the EF-G/GDP complex. Spectrum of activity - Gram-positive cocci

20. Inhibitors of Nucleic Acid Synthesis

21. Inhibitors of RNA Synthesis Selectivity due to differences between prokaryotic and eukaryotic RNA polymerase

22. Rifampin, Rifamycin, Rifampicin, Rifabutin (bactericidal) Mode of action - These antimicrobials bind to DNA-dependent RNA polymerase and inhibit initiation of mRNA synthesis. Spectrum of activity - Wide spectrum but is used most commonly in the treatment of tuberculosis Resistance - Common Combination therapy - Since resistance is common, rifampin is usually used in combination therapy.

23. Inhibitors of DNA Synthesis Selectivity due to differences between prokaryotic and eukaryotic enzymes

24. Quinolones (bactericidal) nalidixic acid, ciprofloxacin, ofloxacin, norfloxacin, levofloxacin, lomefloxacin, sparfloxacin Mode of action - These antimicrobials bind to the A subunit of DNA gyrase (topoisomerase) and prevent supercoiling of DNA, thereby inhibiting DNA synthesis. Spectrum of activity - Gram-positive cocci and urinary tract infections Resistance - Common for nalidixic acid; developing for ciprofloxacin

25. Antimetabolite Antimicrobials

26. Inhibitors of Folic Acid Synthesis Basis of Selectivity Review of Folic Acid Metabolism p-aminobenzoic acid + Pteridine Dihydropteroic acid Dihydrofolic acid Tetrahydrofolic acid Pteridine synthetase Dihydrofolate synthetase Dihydrofolate reductase Thymidine Purines Methionine TrimethoprimSulfonamides

27. Sulfonamides, Sulfones (bacteriostatic) Mode of action - These antimicrobials are analogues of para- aminobenzoic acid and competitively inhibit formation of dihydropteroic acid. Spectrum of activity - Broad range activity against gram-positive and gram-negative bacteria; used primarily in urinary tract and Nocardia infections. Resistance - Common Combination therapy - The sulfonamides are used in combination with trimethoprim; this combination blocks two distinct steps in folic acid metabolism and prevents the emergence of resistant strains.

28. Trimethoprim, Methotrexate, Pyrimethamine (bacteriostatic) Mode of action - These antimicrobials binds to dihydrofolate reductase and inhibit formation of tetrahydrofolic acid. Spectrum of activity - Broad range activity against gram-positive and gram-negative bacteria; used primarily in urinary tract and Nocardia infections. Resistance - Common Combination therapy - These antimicrobials are used in combination with the sulfonamides; this combination blocks two distinct steps in folic acid metabolism and prevents the emergence of resistant strains.

29. Anti-Mycobacterial Antibiotics

30. Para-aminosalicylic acid (PSA) (bacteriostatic) Mode of action - Similar to sulfonamides Spectrum of activity - Specific for Mycobacterium tuberculosis

31. Dapsone (bacteriostatic) Mode of action - Similar to sulfonamides Spectrum of activity - Used in treatment of leprosy (Mycobacterium leprae)

32. Isoniazid (INH) (bacteriostatic ) Mode of action - Isoniazid inhibits synthesis of mycolic acids. Spectrum of activity - Used in treatment of tuberculosis Resistance - Has developed

33. Antimicrobial Drug Resistance Principles and Definitions Clinical resistance Resistance can arise by mutation or by gene transfer (e.g. acquisition of a plasmid) Resistance provides a selective advantage Resistance can result from single or multiple steps Cross resistance vs multiple resistance –Cross resistance -- Single mechanism-- closely related antibiotics –Multiple resistance -- Multiple mechanisms -- unrelated antibiotics

34. Antimicrobial Drug Resistance Mechanisms Altered permeability –Altered influx Gram negative bacteria –Altered efflux tetracycline Inactivation –  -lactamse –Chloramphenicol acetyl transferase

35. Antimicrobial Drug Resistance Mechanisms Altered target site –Penicillin binding proteins (penicillins) –RNA polymerase (rifampin) –30S ribosome (streptomycin) Replacement of a sensitive pathway –Acquisition of a resistant enzyme (sulfonamides, trimethoprim)