Antimicrobials:

General Concepts of
Antibacterials, Antivirals &
Antifungals
Dr Rosa Gualano
Monash University & Monash Health
Formerly - Department of Pharmacology &Therapeutics
[email protected]
 Overall Outline of Lectures
• Key Aspects of Bacteria, Viruses & Fungi
• Key Aspects of Infection
• Selective Toxicity
 Overall Outline of Lectures
• Key Aspects of Bacteria, Viruses & Fungi
• Key Aspects of Infection
• Selective Toxicity
• Drug Categories & Relevant Examples
• Mechanisms of Action
• Mechanisms of Resistance
• The future of antimicrobials
 Main Learning Objectives
Students should be able to:
• Describe the mode of action and selective
toxicity of the main groups of
antimicrobials
• Understand and describe the main
principles of wise antimicrobial use.
 Classification of Microbes

• This is important in deciding which drugs to use

• Bacteria and viruses are classified by their
physical properties and mode of replication –
• Target species, site of infection and virulence
are only MINOR considerations in classification
Many different bacteria cause wound and chest
infections
 Bacterial Properties: General
• Kingdom, Phylum, Class, Order, Family,
Genus, Species
• Correct terminology is Genus then species
Streptococcus pneumoniae, then S. pneumoniae
• Animals, plants, fungi – eukaryotes
 Bacterial Properties: General
• Kingdom, Phylum, Class, Order, Family,
Genus, Species
• Correct terminology is Genus then species
Streptococcus pneumoniae, then S. pneumoniae
• Animals, plants, fungi - eukaryotes
• Bacteria: prokaryotic, unicellular micro-organisms
usually multiply by cell division
have a cell wall (except for mycoplasma)
may be aerobic or anaerobic
motile or non-motile.
 Bacterial Properties: Intracellular
• In comparison to our cells, Prokaryotes lack
paired chromosomes
mitotic cell division, microtubules,
mitochondria & a nuclear membrane.
• Prokaryotes have simultaneous, co-located
transcription and translation.
Eukaryotes: transcription in the nucleus,
translation of mRNA into protein in the cytoplasm
• Ribosomes have a different structure
• Distinct structures and processes can be drug
targets
 Bacterial Classification: Gram Stains
• Stain reflects different cell wall structures
• Peptidoglycan: cell wall polymer of hexose
sugars & amino acids
• Unique to bacteria
• Layer is thicker in G+,
so initial stain remains
after acid alcohol wash

Gram reaction is a key factor in choosing the right antibiotic

 Bacterial Classification: Structure
• Cocci, bacilli, spirochete
some bacilli have heat resistant spores

• Pili (fimbriae) mediate

attachment
• Flagella permit movement
Influences site of infection &
immune response
• Polysaccharide capsule can
be a major virulence factor (immune evasion)
 Classification: Metabolism
• Aerobic (obligate or facultative) or anaerobic
respiration
• Anaerobic respiration makes less ATP
Anaerobic bacteria cause serious & diverse disease
• Nutritional requirements are variable but this
only partly influences virulence
• Specific metabolic pathways can be drug targets
folate synthesis
• Cell wall structures used for nutrient uptake can
be antibiotic targets
 Important Concepts in Infection (I)

• Which bacteria cause these infections?

• What is the antibiotic susceptibility profile?
 Important Concepts in Infection (I)

• Which bacteria cause these infections?

• What is the antibiotic susceptibility profile?
• Where is the infection now?
Where did it start, where could it spread?
Many antibiotics do not penetrate bones, abscesses
• How might infection damage the host?
Should treatment target infection, host response or both?
Consider toxin-mediated pathology
• Could treatment lead to direct or indirect harm?
Steroids can worsen some infections,
antibiotic resistant bacteria can spread to more vulnerable hosts
 Important Concepts in Infection (II)

• Which other infections might be present

but inapparent?
• Could this infection indicate or relate to
immune suppression or chronic illness?
Immune suppression can be temporary or long term –
examples?
• How may this infection be spread?
• Who else may be affected?
 Biofilms
• A surface-attached bacterial community
• Protected from host defences, drying out,
disinfectants & antimicrobials
• Gene expression alters to optimise virulence
• Common with pathogens that cause wound
infections
• Body sites: Dental plaque, heart valves
Devices: joint implants, catheters, contact
lenses
• Care needed with cleaning instruments & tubes
 Antibiotics: History
• Fever therapy: give malaria to treat syphilis
• Paul Ehrlich (Nobel laureate, 1908):
Salvarsan (arsphenamine) to treat syphilis
• Sulfonamides – synthetic metabolic inhibitors
• Natural antibiotics are usually from soil bacteria & fungi
• Penicillin mould impaired bacterial growth
• Often chemically modified to improve pharmacologic and
antimicrobial properties
solubility, stability, acid sensitivity
hepatic metabolism
 From Access
Excellence
Via Google Image.

Penicillium mould inhibits growth of susceptible strains of

Staphylococcus aureus.
 Classification of Antimicrobials
• Antimicrobials:
Antibiotics, Antivirals & Antifungals.
• Classified by target site
chemical structure
Broad vs narrow spectrum
• bacteriocidal or bacteriostatic?
Bacterial replication is delayed, then immune
response clears infection
This may vary with different infections
Bacteriostatic drugs may not be suitable for
immunocompromised patients.
Selective Toxicity of Antimicrobials
Target enzyme or organelle should be
absent or very different in host
 Selective Toxicity of Antimicrobials
Target enzyme or organelle should be
absent or very different in host
• Prodrugs can target infected cells
• If too toxic or poorly absorbed for systemic use -
can use topically in some cases
• Main targets of anti-bacterial drugs:
synthesis of cell walls, nucleic acid & protein
metabolic pathways
cell membrane function.
 Inhibitors of cell wall synthesis:
Penicillins / β-Lactams
• Many agents block cell wall synthesis
• β-Lactams: broad family of drugs that block peptidoglycan
synthesis
Penicillins, cephalosporins, carbapenems
• Transpeptidase target is in the periplasmic space
• First used to treat wound infections & pneumonia
• Targets actively growing bacteria – not active for slow
growing or latent bacteria
 Inhibitors of cell wall synthesis:
Penicillins / β-Lactams
• Early drugs targeted mostly Gram+, coverage expanded
with later drugs
• Hydrophilic drugs (e.g. amoxicillin, piperacillin) more
easily traverse the outer membrane of Gram –ve bacteria
• Hence hydrophilic drugs have a broader spectrum of
antibacterial efficacy
• Hydrophobic β-lactams (e.g. dicloxacillin, penicillin G and
methicillin) have a more narrow spectrum
• Use of narrower spectrum agents is less likely to select
for resistant bacteria
 Clinical uses of β-lactams
• Penicillins (amoxi-, dicloxacillin), are still useful for:
tonsillitis, strep throat, some ear, chest,
dental and skin infections.
• Cephalosporins (ceftriaxone, ceftazidime) are
bacteriocidal and used for typical infections of the:
chest, middle ear, throat, wounds & genitourinary tracts,
also endocarditis, meningitis & Lyme disease.
• Progressive development of Gram –ve activity has often
been linked to decreased activity against Gram + bacteria
 Other β-lactams
• Carbapenems (erta-, mero- doripenem); broad
spectrum,
Mostly used in hospital for serious infections
(wounds, ventilator pneumonia, septicaemia)
Resistance is now emerging via mobile genetic
elements -
(New Delhi metallo-β- lactamase or NDM-1),
which has been associated with medical and dental
tourism.
 Clinical limitations of β-lactams
• Short half lives → dosing 2- 4 times/day needed
• Penicillin G, & some cephalosporins are acid
sensitive → injection or I.V. dosing
• Some bacteria are innately resistant:
Bacteria that lack conventional cell walls
Chlamydia and Mycoplasma
Obligate intracellular parasites
Chlamydia, Rickettsia & others which cannot
make ATP, NAD & other essential factors
Mammalian cells usually lack β-lactam uptake
mechanisms
 Resistance to β-Lactams
• Resistance mediated by
Target site (penicillin binding protein) change
Reduced access to target site (porins)
β-lactamases secreted into periplasmic space (G-) or
extracellularly (G+)
• β-lactamases are often encoded on plasmids
which can readily jump across strains
• β-lactamase inhibitors can be given with antibiotic
Clavulanic acid (Augmentin & related generics) is
useful for tonsillitis, chest & urinary tract infections
Also used in dentistry – but only if really necessary!
 Inhibitors of cell wall synthesis:
Glycopeptides
• Acts at earlier step than β lactams
• Large molecules, poor penetration of G-
• I.V. or i.m. dosing, side effects occur
• Last resort for severe systemic infections, or
when other antibiotics are contra-indicated
• Resistance emerging, especially in enteric
bacteria
Vancomycin & teicoplanin
 Inhibitors of protein synthesis:
Aminoglycosides
• Stops translation of mRNA to protein
• Bacteriocidal, narrow therapeutic index
• Used i.v. or i.m. for severe infections
Poor oral absorption, nephrotoxic & ototoxic
 Inhibitors of protein synthesis:
Aminoglycosides
• Stops translation of mRNA to protein
• Bacteriocidal, narrow therapeutic index
• Used i.v. or i.m. for severe infections
Poor oral absorption, nephrotoxic & ototoxic
• Very active for G-, some activity for G+
• Resistance: enzymatic modification of
drug & altered binding site
Gentamycin, streptomycin, tobramycin*, neomycin*,
framycetin* (*often used topically)
 Inhibitors of Protein Synthesis:
Tetracyclines
• Block tRNA binding to ribosome
• Bacteriostatic, Broad spectrum, orally stable
• Useful for intracellular bacteria & malaria
Chlamydia, Rickettsia, Borrelia, Legionella
• Gut absorption reduced by Ca, Mg & food
• NOT for pregnant women or children < 8
• Resistance (common) due to efflux pump
Tetracycline, doxycycline, minocycline
Karunajeewa H. The Conversation, 26/12/2016
 Inhibitors of protein synthesis:
Macrolides
• Mostly active for G+, some G- activity
• Skin & respiratory infections
Mycoplasma pneumoniae, Legionella pneumophila
• Orally active but do not access CNS
• N & V common but generally safe
• Some anti-inflammatory activity
• Resistance due to altered ribosomes
Erythro-, clarithro-, azithro-, roxithromycin
 Chloramphenicol
• Bacteriostatic, very broad spectrum
• Widely used to treat conjunctivitis (now OTC)
• Targets bacterial ribosome 50S subunit but also
host mitochondrial ribosomes
• Well absorbed and distributed BUT
also suppresses blood cell formation in bone marrow
inhibits liver enzymes involved in drug metabolism
mostly limited to topical use
• Systemic use is uncommon; usually reserved for severe
infections where there is no alternative (meningitis)
Inhibitors of Nucleic Acid Synthesis
• Quinolones block chromosomal replication
• Severe respiratory & urogenital infections
Moxi-, levo- and ciprofloxacin
• Rifampicin blocks mRNA synthesis
• Targets DNA dependent RNA polymerase
Part of combination therapy for TB
 Inhibitors of Metabolic Pathways
• Folate is a cofactor in purine & pyrimidine synthesis
• Bacteria produce folate, humans do not
• Sulfonamides and trimethoprim
block consecutive steps in folate synthesis
mid-1930s: first antibiotic in clinical use
G+ and - including UTI treatment, Pneumocystis
Allergic/adverse reactions common, esp. in HIV
Resistance due to reduced enzyme affinity
• Not in Australian dental guidelines, but still used
 Metronidazole
• Useful for a broad spectrum of anaerobes & protozoa
• In anaerobic cells, unique enzymes convert the prodrug
to short-lived, reduced intermediates that damage DNA
• Abscesses can be an anaerobic microenvironment
• Surgical prophylaxis, STIs, dentistry, wounds

Metronidazole affects
taste, alcohol causes
adverse effects
 Clindamycin & lincomycin
• Protein synthesis inhibitors, reserved for serious
infections
bone, wounds, deep dental infection, pneumonia
• Second line therapy, reserved for resistant bacteria
(Staph. Aureus) & anaerobes, penicillin allergic
patients
• GI side effects common but can cause severe
diarrhoea, especially in elderly patients and/or
patients on medication that slows bowel contractions
Summary: sites of action of anti-bacterial drugs

From: Principles of Pharmacology (2012) Golan et al. (editors) 3rd edition.

 Adverse Effects of Antibiotics
• Allergies: most common with penicillins &
tetracyclines
• Distinguish from intolerance: nausea, vomiting,
diarrhoea, rash
• Only 10-20% of self-reported penicillin allergy is
genuine*, BUT
• Penicillin anaphylaxis can be serious
Most cephalosporins are safe for non-anaphylactic
penicillin allergy
Slow IV dosing may help sensitive patients
* Salkind et al. (2001) JAMA 285(19): 2498.
 Adverse Effects of Antibiotics
• Adverse effects may be unrelated to target
many interfere with absorption of oral contraceptives
macrolides → warfarin accumulation
• Caution needed in polypharmacy patients
• Management of adverse effects:
• Education on what to expect
• wise choice of dose & duration, monitoring
 Adverse events associated with
antibiotics in hospitalized patients
 Retrospective review of 1488 adult inpatients (median of
59 years, IQR 49 – 69)
 20% of patients had at least 1 antibiotic associated AE
GI, renal and haematologic were most common
 20% of non-clinically indicated regimens were associated
with an AE, incl. 7 cases of Clostridium difficile
 Every additional 10 days of antibiotics conferred a 3%
increased risk of AEs

Tamma PD et al. (2017) JAMA Internal Med. 177(9):

1308-1315.
 Use in Pregnancy & Lactation
• Infection risks increased in pregnancy
• Urinary tract & Dental infections common
• Possible harm due to untreated infections
Antibiotics can usually be given when needed!
• Penicillins, newer macrolides, metronidazole usually OK
• Tetracyclines, fluoroquinolones NOT safe
• Weaning can be temporary but expressing is required to
maintain milk supply

Check Therapeutic Guidelines

George et al. (2017) Aust Dental Journal 62: 301 – 310.
Antimicrobial treatment strategies
• Prophylactic
Just before the procedure (NOT ongoing)
• Empirical
Pathogen ID is not justified or possible
Treatment cannot wait for pathogen ID
• Directed
Justified in complex, high risk patients
Distinguish pathogens from normal flora

Oral & Dental Therapeutic Guidelines (2012) p. 14 - 16

 Considerations in Dentistry
• Acute oral infections; Antibacterial must
match the pathogen
be combined with appropriate dental treatment
reach the site of infection via bloodstream
be bacteriocidal.
• Counsel patient on:
likely timeframe of improvement
possible adverse effects
when to seek advice

Aminoshariae & Kulild (2016) J Am Dent Assoc 147(3):186-191

 Endocarditis prophylaxis
 Incidence of endocarditis is 3-10 per 100,000 people
 Mortality rate is ~20%
 ~50% of cases have no known cardiac risk factors
 Main pathogens are staphylococci and streptococci
 Major variation in international guidelines for antibiotic
prophylaxis
Difficult to link guideline compliance with rates of endocarditis –
many confounding factors
 Limited use of penicillins or clindamycin justified for
some invasive procedures, for some high risk cardiac
patients
Daly CG (2017) Australian Prescriber 40(5): 184-188
 Which antibiotics are commonly
prescribed by dentists?
• Analysis of dental prescribing, 2013 – 16:
64% amoxicillin
13-14% metronidazole
10.4% (and rising) amoxicillin + clavulanic acid
5% clindamycin
3% cephalexin
1.4% for each of penicillin V and erythromycin
• Dental prescribing is lower in Australia than other
countries, but guideline compliance can be improved
Teoh et al. (2018) Aust Dental Journal 63: 329 - 337
 Antimicrobial Resistance
• Microbe not killed by typical in vivo doses
• Resistance may be innate (primary)
Lack of target site or drug impermeability
• Resistance may be acquired (secondary)
Spontaneous chromosomal mutation(s)
Gene transfer on transposon or plasmid
• Resistance must confer an evolutionary
advantage, not a metabolic cost
• MRSA in USA: 105 infections, 20,000 annual deaths
Susceptibility profile of a
range of antibiotics

Susceptibility testing of a dilution

From Google Image series of one antibiotic
 Development of antibiotic
resistance by gradual mutation

https://www.youtube.com/watch?v=plVk4N
VIUh8

In an environment where antibiotics are

constantly present, evolution of resistance
confers an advantage to bacteria
Mechanisms of Antibacterial Resistance
• Target site has less affinity for drug
Enzyme / organelle must still function
• Reduced influx or increased efflux of drug
Tetracycline uptake requires active transport
• Induction of enzymes that alter or destroy the
drug
secreted beta-lactamases
• Modern antibiotics neutralise resistance
Augmentin: amoxycillin + clavulanic acid
See also:
Prof. Allen Cheng

Long courses, confusion

and culture: why we’re
losing the fight against
antibiotic resistance.

The Conversation
13/1/2016
It is important to minimise use
in minor or self-limiting infections.

The dose should be:

High enough to treat infection and

minimise selection of resistant
variants, and for

Long enough to resolve infection,

BUT

Low enough to minimise adverse

reactions, especially in the elderly
and other vulnerable groups.
 Concluding Points
• Be mindful of:
Which bacteria could cause this infection?
Is the infection self limiting?
Is this antibiotic appropriate?
resistance, access, other barriers to efficacy
Special characteristics of the patient
age, pregnancy, immunosuppresion, GI / kidney /
cardiac co- morbidities
Minimizing needless use of antibiotics.