1. Pharmacology-1 PHL 211
2nd Term 11th Lecture By Abdelkader Ashour, Ph.D. Phone:

2. Metronidazole
Metronidazole is a synthetic, nitroimidazole-derivative antibacterial and antiprotozoal agent
Metronidazole has been shown to be carcinogenic in mice and rats. Unnecessary use of the drug should be avoided.
Mechanism of Action:
Metronidazole is activated (reduced) by the microbial proteins flavodoxins and ferredoxins found in anaerobic bacteria and certain protozoans
Mammalian cells are unharmed because they lack flavodoxins and ferredoxins that reduce the nitro group of metronidazole
Flavodoxins and ferredoxins are electron-transfer proteins that serve as electron donors in the reductive activation of anaerobic ribonucleotide reductase, biotin synthase,…etc
Once activated, the drug (a short-lived reduction product, most probably the protonated one electron nitro radical anion) oxidizes DNA causing strand breaks and subsequent cell death

3. Metronidazole, Clinical Uses
Amebiasis
Metronidazole is the drug of choice for the treatment of all tissue infections with Entamoeba histolytica
It is not reliably effective against luminal parasites and so must be used with a luminal amebicide to ensure eradication of the infection
Tinidazole, a related nitroimidazole, appears to have similar activity and a better toxicity profile than metronidazole
Giardiasis
Metronidazole is the treatment of choice for giardiasis
The dosage for giardiasis is much lower— and the drug thus better tolerated—than that for amebiasis
Efficacy after a single treatment is about 90%
Tinidazole is equally effective
Trichomoniasis
Metronidazole is the treatment of choice. A single dose of 2 g is effective
Metronidazole-resistant organisms may lead to treatment failures
Tinidazole may be effective against some of these infections
T. vaginalis infection is a venereal disease. Therefore, asymptomatic sexual partners of treated patients should be treated simultaneously if the organism has been found to be present, in order to prevent re-infection of the partner

4. Metronidazole, Clinical Uses, contd.
Bacterial Infections
Metronidazole has potent antibacterial activity against anaerobes, including bacteroides and clostridium species
Metronidazole is indicated for treatment of anaerobic or mixed intra-abdominal infections, vaginitis (bacterial vaginosis), antibiotic-associated enterocolitis, acute gingivitis and other dental infections
Metronidazole is indicated for treatment of vaginitis due to bacterial Gardnerella or Mycoplasma hominis infection in symptomatic patients
Helicobacter pylori eradication therapy, as part of a multi-drug regimen in peptic ulcer disease

5. Metronidazole, Adverse Effects
Convulsive seizures and peripheral neuropathy (with prolonged use) are serious adverse effects, however they are rare
Nausea, vomiting, diarrhea, epigastric distress, abdominal cramping and constipation. Taking the drug with meals lessens gastrointestinal irritation
A sharp, unpleasant metallic taste, furry tongue, glossitis, dry mouth and stomatitis. These may be associated with a sudden overgrowth of Candida which may occur during therapy
Proliferation of Candida in the vagina, dysuria, polyuria, dark urine, cystitis, incontinence and proctitis
Reversible neutropenia (leukopenia) and reversible thrombocytopenia
Although teratogenic in some animals, metronidazole has not been associated with this effect in humans
Metronidazole and its metabolites are mutagenic in bacteria. Chronic administration of large doses led to tumorigenicity in mice and rats

6. Sulphonamides (Sulfonamides)
The sulphonamide drugs were the first effective chemotherapeutic agents to be employed systemically for the prevention and cure of bacterial infections in humans
The advent of penicillin and subsequently of other antibiotics has diminished the usefulness of the sulfonamides
The introduction of the combination of trimethoprim and sulfamethoxazole has increased the use of sulfonamides for the prophylaxis and treatment of specific microbial infections
Mechanism of Action
Sulphonamides, structural analogs and competitive antagonists of para-aminobenzoic acid (PABA), prevent normal bacterial utilization of PABA for the synthesis of folic acid
Sensitive microorganisms are those that must synthesize their own folic acid (cofactor in thymidylate synthesis); bacteria that can use preformed folate are not affected
Bacteriostasis induced by sulfonamides is counteracted by PABA competitively
Sulfonamides do not affect mammalian cells by this mechanism because they require preformed folic acid and cannot synthesize it. Thus, mammalian cells are comparable to sulfonamide-insensitive bacteria that use preformed folate
One of the most active agents that exerts a synergistic effect when used with sulfonamides is trimethoprim (a potent and selective competitive inhibitor of microbial dihydrofolate reductase; the enzyme that reduces dihydrofolate to tetrahydrofolate). Thus, simultaneous administration of a sulfonamide and trimethoprim introduces sequential blocks in the pathway by which microorganisms synthesize tetrahydrofolate from precursor molecules
This combination (e.g., trimethoprim and sulphamethoxazole  Co-trimoxazole) often is bactericidal, compared to the bacteriostatic activity of a sulfonamide alone

7. Sulphonamides Sulphonamides are metabolised in vivo to sulphanilamide
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Examples of sulphonamides: sulfamethoxazole, sulfadiazine, sulfacetamide (topical)

8. Sulphonamides, Actions, Uses, & Side Effects
Sulphonamides are broad spectrum bacteriostatic agents effective against Gram-positive & Gram-negative bacteria
They are bacteriostatic not bactericidal (i.e. they suppress division of the cells but do not kill them), and are therefore only really effective in the presence of adequate host defences
Clinical Uses:
Combined with trimethoprim (co-trimoxazole) for Pneumocystis carinii, which causes pneumonia in patients with AIDS
Combined with pyrimethamine (which interferes with folic acid synthesis by inhibiting the enzyme dihydrofolate reductase) for drug-resistant malaria, and for toxoplasmosis
For infected burns (silver sulfadiazine given topically)
Sulfonamides are as efficacious as oral penicillin in preventing streptococcal infections and recurrences of rheumatic fever among susceptible subjects
For some sexually transmitted infections (e.g. trachoma, chlamydia)
For urinary tract and respiratory infections
Side effects:
Nausea and vomiting, headache and mental depression
Cyanosis caused by methaemoglobinaemia may occur
Serious adverse effects include hepatitis, hypersensitivity reactions (rashes, fever, anaphylactoid reactions), bone marrow depression and crystalluria. This last effect results from the precipitation of acetylated metabolites in the urine

9. Antifungal Agents, Overview
Fungi are plant-like non-photosynthetic Eukaryotes that may exist in colonies of single cells (yeast) or filamentous multicellular aggregates (molds or hyphae)
Human fungal infections have increased dramatically in incidence and severity in recent years, due mainly to:
cancer treatment and the HIV epidemic (why? Is immune system involved?)
critical care accompanied by increases in the use of broad-spectrum antimicrobials
Fungal infections can be divided into:
superficial infections (affecting skin, nails, scalp or mucous membranes)
systemic infections (affecting deeper tissues and organs)
The treatment of superficial fungal infections caused by dermatophytic fungi may be accomplished with:
Topical antifungal agents, e.g., clotrimazole, miconazole, terbinafine, ketoconazole
Orally administered agents, e.g., fluconazole, terbinafine, ketoconazole
Superficial infections caused by candida species may be treated with topical applications of clotrimazole, miconazole, ketoconazole, nystatin, or amphotericin B
Chronic generalized mucocutaneous candidiasis is responsive to long-term therapy with oral ketoconazole
Many antifungal agents are quite toxic, and when systemic therapy is required these agents must often be used under strict medical supervision