BETA – LACTAM ANTIBIOTICS

PENICILLINS & CEPHALOSPORINES

EMRE, THE BARBARIAN
YEDITEPE (SEVEN HILL?)
FALL 2010
PATHOGENIC BACTERIA
FIRST, A BRIEF INTRODUCTION AND SUMMARY OF PATHOGENIC
BACTERIA
Eukaryotic and Prokaryotic Cells
Prokaryotes Eukaryotes
(GR: Before nucleus) (GR: True nucleus)
No membrane around Nuclear membrane -
DNA – NO NUCLEUS. NUCLEUS
Smaller than eukaryotes 10-100 µm
(approx. 1.0 µm in Algae, protozoa, fungi,
diameter) animals, plants
Bacteria and archaea. Large and more
Simple and small complex than
prokaryotes
Prokaryote cell
Another picture of prokaryotic cell
Eukaryote cell
Another picture of eukaryotic cell
 comparison
What major difference?
Eukaryotes contain
nuclei, visible with
light microscopy.
Prokaryotes lack
nuclei.
What else?

Prokaryotic ribosomes are

70S and composed of 30S
and 50S subunits.
Eukaryotic ribosomes are
80S with 60S and 40S
subunits.
Morphology of prokaryotic cells
PATHOGENIC BACTERIA

… BOTH WONDERFUL, POWERFUL AND

HORRIBLE CREATURES THAT SELF-REPLICATE
AND SURVIVE IN THE HARSH AND HOSTILE
ENVIRONMENT OF THE HUMAN BODY.
The major groups of medically important
bacteria

This illustration is a
practical
representation of the
principal groups of
pathogenic bacteria.
It is meant to be a
study aid, not a
taxonomic or
phylogenetic tree.
 USUAL SUSPECTS & KOCH
Although the vast majority of bacteria are harmless or
beneficial, quite a few bacteria are pathogenic.
LET’S REMEMBER SOME “USUAL SUSPECTS”.
TUBERCULOSIS: Mycobacterium tuberculosis kills
about 2 million people a year, mostly in sub-Saharan
Africa.
PNEUMONIA: Streptococcus and Pseudomonas
FOODBORNE INFECTIONS: Shigella,
Campylobacter and Salmonella.
Pathogenic bacteria also cause infections such as tetanus,
typhoid fever, diphtheria, syphilis and leprosy.
Koch's postulates are criteria designed to establish a causal
relationship between a causative microbe and a disease.
KOCH’S POSTULATES
Koch's postulates are four criteria
designed to establish a causal
relationship between a causative
microbe and a disease. The
postulates were formulated by
Robert Koch and Friedrich
Loeffler in 1884 and refined and
published by Koch in 1890. Koch
applied the postulates to establish
the etiology of anthrax and
tuberculosis, but they have been
generalized to other diseases.
KOCH’S FOUR POSTULATES
1. The microorganism must be found in abundance
in all organisms suffering from the disease, but
should not be found in healthy animals.
2. The microorganism must be isolated from a
diseased organism and grown in pure culture.
3. The cultured microorganism should cause
disease when introduced into a healthy
organism.
4. The microorganism must be reisolated from the
inoculated, diseased experimental host and
identified as being identical to the original
specific causative agent.
Pathogenic bacteria: conditional or
intracellular
CONDITIONALLY PATHOGENIC:
PART OF THE HUMAN FLORA
PATHOGENIC ONLY UNDER CERTAIN
CONDITIONS: WOUND OR IMMUNODEFICIENCY
Staphylococcus or Streptococcus SPECIES
Pseudomonas aeruginosa, Burkholderia cenocepacia,
and Mycobacterium avium, are opportunistic pathogens
and cause disease mainly in people suffering from
immunosuppression or cystic fibrosis.
INTRACELLULAR
INTRACELLULAR PATHOGENS
Facultative intracellular parasites are capable of
living and reproducing either inside or outside cells.
Bacterial examples include Neisseria meningitidis,
Francisella tularensis and Listeria monocytogenes.
Other examples include Brucella, Legionella,
Mycobacterium, and Yersinia.
A fungal example is Histoplasma capsulatum.
Obligate intracellular parasites cannot reproduce
outside their host cell, meaning that the parasite's
reproduction is entirely reliant on intracellular
resources.
 OBLIGATE
Viruses Certain protozoa,
Certain bacteria, including:
including: Plasmodia species
Chlamydia, and closely Leishmania spp.
related species.[3] Toxoplasma gondii
Rickettsia Trypanosoma cruzi
Coxiella
Certain species of
Mycobacterium such as
Mycobacterium
The mitochondria in eukaryotic cellsleprae
may also have originally been such parasites, but ended
up forming a mutualistic relationship (endosymbiotic theory).
Study of obligate pathogens is difficult because they cannot usually be reproduced outside
the host. However, in 2009 scientists reported a technique allowing the Q-fever pathogen
Coxiella burnetii to grow in an axenic culture and suggested the technique may be useful for
study of other pathogens.
 ENDOSYMBIOTIC THEORY
The endosymbiotic theory concerns the origins of mitochondria and plastids (e.g.
chloroplasts), which are organelles of eukaryotic cells. According to this theory, these
organelles originated as separate prokaryotic organisms that were taken inside the cell as
endosymbionts. Mitochondria developed from proteobacteria (in particular, Rickettsiales or
close relatives) and chloroplasts from cyanobacteria.
 EXAMPLES OF NORMAL BACTERIAL
FLORA (NORMAL MICROBIOTA)

THE HUMAN BODY CONTAINS A VAST NUMBER OF PATHOGEN ORGANISMS

THAT MAKE UP THE NORMAL HUMAN FLORA.
We must know what microorganisms live in what parts of our body to decide whether
there is an infection or a colonization.
Description
Contamination: mere presence of microbes in or on the body.
Food, drink or air: External contaminants.
Wounds, biting arthropods (bugs), sexual intercourse.
Colonization: microbial contaminants remain where they first
contacted the body without causing any harm (Staphylococcus
epidermidis on the skin; pathogens in mucous membranes) and
they become part of the RESIDENT MICROBIOTA or got rid
of and become TRANSIENT MICROBIOTA.
Infection: successful invasion of the body by a pathogen. The
pathogen that entered the body through contamination
overcame the body’s defenses.
 Resident microbiota I

Ref: Chapther 14: Infection, Infectious Diseases and Epidemiology. Microbiology; Alternate Edition with Diseases
by Body System. Robert W. Bauman, Ph.D. Pearson Benjamin Cummings. 2006. pp 408-409
Resident microbiota II
How normal microbiota becomes
opportunistic pathogens
IMMUNE SUPPRESSION
Disease (AIDS, renal insufficiency, hepatitis), malnutrition,
emotional stress, physical stress, extremes of age (very young or
very old), radiation, chemotherapy, immunosuppressive drugs
CHANGES IN THE NORMAL MICROBIOTA
Use of antimicrobials can lead to formation of Candida albicans
in the vagina.
Hormonal changes, stress, changes in diet
Exposure to overwhelming number of pathogens
INTRODUCTION OF A MEMBER OF THE NORMAL
MICROBIOTA INTO AN UNUSUAL SITE IN THE BODY
Ex. Rectal-vaginal transmission of E coli, entering urethra
Let us remember Koch’s postulates
It is critical that all the postulates are satisfied in this
order.

1. The suspected pathogen must be present in every

case of the disease.
2. The pathogen must be isolated and grown in pure
culture.
3. The cultured pathogen must cause the disease when
it is inoculated into a healthy, susceptible
experimental host.
4. The same pathogen must be reisolated from the
diseased experimental host.
Exception to Koch’s postulates
Some pathogens can not be cultured in the laboratory:
Mycobacterium leprae
Some diseases are cuased by a combination of
pathogens OR a combination of pathogen and other
cofactors (environmental or genetic):
Liver cancer: when both hepatitis B and hepatitis D
Ethical considerations prevent applying to Koch’s
postulates to diseases and pathogens that occur in
HUMANS ONLY!
AIDS: observations of fetuses of infected mothers or of
healthcare workers who were infected accidentally
Difficulties against Koch’s postulates
Single cause not possible:
Pneumonia, meningitis, hepatitis
Ignoring some pathogens
Helicobacter pylori and gastric ulcers
Virulence factors of Infectious Agents
Pathogenicity: the ability of a mo to cause disease.
Virulence: the degree of pathogenicity.
Virulence: the relative ability of a pathogen to infect a
host and cause disease.
Virulence factors: traits of pathogens that enable them
to enter a host, adhere to host cells, gain access to
nutrients, escape detection or removal of the host cell.
Virulence continuum
More virulent
Francisella tularensis (rabbit fever)
 Yersinia pestis (plague)
 Bordetellapertussis (whooping cough)
o Pseudomonas aeruginosa (infections of burns)
• Clostridium difficile (antibiotic induced / pseudomembraneuse
collitis)
• Candida albicans (vaginitis, thrush)
• Lactobacilli (diphtheroidis)
• Less virulent
The “Big Four” typical bacteria
The four categories presented in Figure are fairly
evenly represented in the normal flora of:
the mouth,
the pharynx, and
the large intestine;
major pathogens, however, are represented in fewer
numbers.
The Gram-positive cocci and the Gram-negative rods
are the most common agents of infection, followed by
the Gram-negative cocci and the Gram-positive rods.
 Diseases caused by selected Gram (+)
Bacteria
Genera Characteristics Diseases
Clostridium Obligate anaerobic rods Tetanus
(endospore formers) Botulism
Gangrene
Severe diarrhea
(pseudomembraneouse
collitis)
Epulopiscium Giant rods Dental caries
Veillonella Part of oral biofilm on Dental caries
human teeth; stain like
Gram (-) / PINK
Mycoplasma No cell wall; pleomorphic, Pneumonia
smallest free-living cells, Urinary tract infections
stain like Gram (-) / PINK
Bacillus Facultative anaerobic rods; Anthrax
endospore formers
Listeria Contaminates of dairy Listeriosis
products
 Diseases caused by selected Gram (+)
Bacteria
Genera Characteristics Diseases
Lactobacillus Produce yogurt, buttermilk, Rare blood infections
pickles, sauerkraut
Streptococcus Cocci in chains Strep throat, scarlet fever,
and others
Staphylococcus Cocci in clusters Bacteremia, food poisoning,
and others
Corynebacterium Snapping division; Diphtheria
metachromatic granules in
cytoplasm
Mycobacterium Waxy cell walls (mycolic Tuberculosis and meningitis
acid)
Actinomyces Filaments Actinomycosis
Nocardia Filaments; degrade Lesions
pollutants
Streptomyces Produce antibiotics Rare sinus infections
 Diseases caused by selected Gram (-)
Bacteria
Genera Characteristics Diseases
Rickettsia Intracellular pathogens Typhus
Rocky Mountain spotted
fever
Brucella Coccobacilli Brucellosis
Ehrlichia Live inside white blood Leukopenia
cells
Neisseria Diplococci Gonorrhea and meningitis
Burkholderia Lung infection of cystic
fibrosis patients
Legionella Intracellular pathogens Legionnaires’ disease
Coxiella Intracellular pathogens Q fever
Pseudomonas Aerobes that catabolize Urinary tract infections,
carbohydrates via Entner- external otitis
Doudoroff and pentose
phosphate way
Diseases caused by selected Gram (-) Bacteria
Genera Characteristics Diseases
Campylobacter Curved rods Gastroenteritis
Helicobacter Spirals Gastric ulcers
Treponema Spirochetes Syphilis
Borrelia Spirochetes Lyme disease
Bacteroides Anaerobes that live in Abdominal infections
animal colons
Escherichia Straight rods Gastroenteritis
Salmonella (Enterobacteriaceae) Enteritis
Facultative Anaerobes
Proteus Urinary tract infections
Shigella Shigellosis
Yersinia Plague
Klebsiella Pneumonia
Vibrio Vibrios (Vibrionaceae) Cholera
Haemophilus Cocci or straight rods Meningitis in children
(Pasteurellaceae)
ANTIBIOTICS
WHAT ARE THEY? HOW DO THEY WORK?
ANTIBIOTICS – secondary metabolites
MEMBERS of extremely diverse group of metabolites
known as secondary metabolites.
Secondary metabolites are complex organic molecules
that are not essential for normal cell growth.
Tetracyline: 72 separate enzymatic steps
(Streptomyces)
Erythromycine: 25 different chemical reactions
(Streptomyces).
Therefore, antibiotics are “expensive” to bacteria.
Also: in natural soil, antimicrobials are not found at
concentrations inhibitory to neighbouring cells.
Why are there antibotics for m.o.?
Leftovers of metabolic pathways that were once
beneficial?
Truly required by the host cell to defend itself?
These hypotheses are not proven, but…
Antibiotics are very useful for the mankind to defend
against infections.
 Sources of some common antibiotics
MICROORGANIS ANTIMICROBIAL
M
FUNGI
Penicillum Penicillin
chrysogenum
Penicillium Griseofulvin MICROORGANIS ANTIMICROBIA
griseofulvin M L
Cephalosporium Cephalothin BACTERIA CONTINUED
spp.
Streptomyces Vancomycine
BACTERIA orientalis
Bacillus Bacitracin Streptomyces Chloramphenicol
licheniformis venezuelae
Bacillus polymyxa Polymyxin Streptomyces Erythromycin
Micromonospora Gentamicin erythraeus
purpurea Streptomyces Rifampin
Streptomyces griseus Streptomycin mediterranei
Streptomyces fradiae Neomycin Streptomyces Amphotericin B
nodosus
Antibiotics Selection
Culture and sensitivity testing prior to antibiotic
prescribing.
Empirical antibiotic therapy should be based on:
Knowledge of likely pathogens for the site of infection
Anamnesis and patient history: recent hospitalizations,
work-related exposure, travel, pets, etc.
Local susceptibility
THREE MAIN WAYS TO ATTACK
PATHOGENIC BACTERIA
KNOW THY ENEMY AND KNOW YOURSELF; IN A
HUNDRED BATTLES YOU WILL NEVER BE IN PERIL.
THE ART OF WAR, SUN TZU

1. THE BACTERIAL CELL ENVELOPE

A UNIQUE STRUCTURE NOT PRESENT IN HUMANS

2. BIOSYNTHETIC PROCESSES WITHIN THE

BACTERIA
BACTERIAL PROTEIN PRODUCTION

3. BACTERIAL REPLICATION (DNA)

Antibiotic
Mechanisms of
Action
Mechanisms of action
Beta lactams attack cell wall
– what is it?
Most bacteria have a cell
wall, composed of
PEPTIDOGLYCAN.
Peptidoglycan is a complex
polysaccharide.
Peptidoglcan is composed of
two regularly alternating
sugars:
NAM: N-Acetylmuramic
Acid
NAG: N-Acetylglucosamine
Structure of peptidoglycan
 Comparison of cell walls – Gram (+) &
Gram (-)

What is the effect of

Lipid A on humans?
Lipid A causes shock,
blood clotting and fever
in humans!
CELL ENVELOPE
GRAM POSITIVE GRAM NEGATIVE
CYTOPLASMIC MEMBRANE CYTOPLASMIC MEMBRANE
SURROUNDED BY TOUGH SURROUNDED BY THE
AND RIGID CELL WALL OUTER MEMBRANE (THIN,
GRAM STAINING: BLUE LIPID MEMBRANE)
GRAM STAINING: PINK
(PURPLE-positive-P)
(negative-N)
CYTOPLASMIC MEMBRANE
PREVENTS IONS FROM FLOWING INTO OR
OUT OF THE CELL ITSELF.
MAINTAINS THE CYTOPLASM AND
BACTERIAL COMPONENTS IN A DEFINED
SPACE.
GRAM (+) / CELL WALL: PROTECTS IT FROM
MECHANICAL AND OSMOTIC STRESSES.
GRAM (-) / MEMBRANE: CONTAINS PORINS
(ION CHANNELS)
HUMAN CELLS: DO NOT CONTAIN A CELL
WALL.
STRUCTURE OF THE CELL WALL
PEPTIDOGLYCAN (LONG SUGAR POLYMERS)
N-ACETYL-GLUCOSAMINE + N-ACETYL-
MURAMIC ACID
+ PEPTIDE SIDE CHAINS
CROSS-LINKED TOGETHER
JUST AS CROSS-LINKING OF METAL LOOPS
STRENGTHENED THE CHAIN MAIL ARMOR USED
BY MEDIEVAL KNIGHTS.
CROSS-LINKING IS MEDIATED BY
PENICILLIN-BINDING PROTEINS (PBPs):
BACTERIAL ENZYMES
Schematic of typical GRAM-POSITIVE cell wall showing arrangement of N-
Acetylglucosamine and N-Acetylmuramic acid; Teichoic acids not shown.
Schematic of typical GRAM-NEGATIVE cell wall showing arrangement of N-
Acetylglucosamine and N-Acetylmuramic acid and the outer membrane containing
lipopolysaccharide.
Resim eklemek için simgeyi tıklatın

A general view of all antibiotics

GRAM POSITIVE & NEGATIVE?
A Gram stain of mixed Staphylococcus aureus (Gram positive cocci, purple) and
Escherichia coli (Gram negative bacilli, pink). (Image: Y Tambe, Wikimedia
Commons)
Resim eklemek için simgeyi tıklatın

ANTIBACTERIAL AGENTS: BETA LACTAMS

PENICILLINS & CEPHALOSPORINES: ATTACKING THE CELL MEMBRANE
IN FIGURE, THE STRUCTURE OF THE BETA LACTAM RING IS SHOWN.
β-Lactam Antibiotics
The essential core of penicillin is a four-member ring
called a β-lactam ring.
Modifications led to penicillins, cephalosporins,
carbapenems, and monobactams.
β-lactam antibiotics: inhibitors of penicillin-binding
proteins (PBPs) that normally assemble the
peptidoglycan layer surrounding most bacteria.
β-Lactams: an important class of
antibacterial compounds.
Cyclic amides with four atoms in the ring and this ring
is more accurately referred to as an azetidinone ring.
Examples of β-lactams include 
penicillins (natural and synthetic), 
cephalosporins (natural and synthetic), cephems (also
known as carbacephems), cephams, penems, penams,
carbapenems, cephamycins, 1-oxacephems,
clavulanic acids (also known as clavams),
nocardicins, trinems (also known as tribactams)
and monobactams.
β-Lactams: an important class of
antibacterial compounds.
Mechanism of action of β-lactam antibiotics
A. Normally, a new subunit of N-
acetylmuramic acid (NAMA) and N-
acetylglucosamine (NAGA)
disaccharide with an attached peptide
side chain is linked to an existing
peptidoglycan polymer. This may
occur by covalent attachment of a
glycine (G) bridge from one peptide
side chain to another through the
enzymatic action of a penicillin-
binding protein (PBP). B. In the
presence of a β-lactam antibiotic, this
process is disrupted. The β-lactam
antibiotic binds the PBP and prevents
it from cross-linking the glycine
bridge to the peptide side chain, thus
blocking incorporation of the
disaccharide subunit into the existing
How does β-Lactam ring do that?
The β-lactam ring mimics the D-alanyl-D-alanine
portion of the peptide side chain that is normally
bound by PBPs. PBPs thus interact with the β-lactam
ring and are not available for synthesis of new
peptidoglycan.
The disruption of the peptidoglycan layer leads to lysis
of the bacterium.
Mechanism of penicillin-binding protein
(PBP) inhibition by β-lactam antibiotics.
A. PBPs recognize and
catalyze the peptide bond
between two alanine
subunits of the
peptidoglycan peptide
side chain. B. The β-
lactam ring mimics this
peptide bond. Thus, the
PBPs attempt to catalyze
the β-lactam ring,
resulting in inactivation
of the PBPs.
RESISTANCE TO BETA
LACTAMS
INTRINSIC ACQUIRED
Pseudomonas Pseudomonas
aeruginosa aeruginosa
the porins in its outer The carbapenem
membrane strains do not “imipenem” gains
allow passage of access to the PBPs of
ampicillin to the this organism by passing
periplasmic space. through a specific
protein channel found in
the outer membrane. 
spontaneous mutations
RESISTANCE TO BETA
LACTAMS
INTRINSIC ACQUIRED
ALL STRAINS ARE SOME STRAINS ARE
RESISTANT. RESISTANT.
THE SIX P’S (SIX POTENTIAL
PITFALLS)
1. Penetration
2. Porins
3. Pumps - efflux pumps
4. Penicillinases (really β-lactamases, but that does not
start with P!)
5. PBPs
6. Peptidoglycan is absent

Six P's by which the action of β-lactams may be blocked.

Six P's by which the action of β-lactams may
be blocked.
1. Penetration
2. Porins
3. Pumps
4. Penicillinases
(β-lactamases)
5. Penicillin-
binding
proteins
(PBPs)
6. Peptidoglycan.
1/6. PENETRATION
β-lactams penetrate poorly into the intracellular
compartment of human cells, so bacteria that reside in
this compartment are not exposed to them.
A β-lactam antibiotic cannot kill a bacterium if it
cannot get to it!
Remember: Facultative and Obligate microorganisms.
2/6. PORINS
If a β-lactam antibiotic does reach the bacterium, it must
gain access to its targets, the PBPs.
In Gram-positive bacteria, this is not difficult because the
PBPs and the peptidoglycan layer are relatively exposed,
but in Gram-negative bacteria they are surrounded by the
protective outer membrane.
β-Lactams must breach this membrane by diffusing through
porins, which are protein channels in the outer membrane.
Many Gram-negative bacteria have porins that do not allow
passage of certain β-lactams to the periplasmic space.
3/6. PUMPS (EFFLUX PUMPS)
Pumps—some bacteria produce efflux pumps, which
are protein complexes that transport antibiotics, which
have entered the periplasmic space, back out to the
environment.
 These pumps prevent antibiotics from accumulating
within the periplasm to concentrations sufficient for
antibacterial activity.
4/6. PENICILLINASES (β-LACTAMASES)
Penicillinases: really β-lactamases, but that does not
start with P!)
Many bacteria, both Gram-positive and Gram-
negative, make β-lactamases, enzymes that degrade β-
lactams before they reach the PBPs.
5/6. PBPs
Some bacteria produce PBPs that do not bind β-
lactams with high affinity.
In these bacteria, β-lactams reach their targets, the
PBPs, but cannot inactivate them.
6/6. PEPTIDOGLYCAN
Peptidoglycan is absent—there are a few bacteria that
do not make peptidoglycan and that therefore are not
affected by β-lactams.
EFFECTIVE β-LACTAMASE
INHIBITORS* ARE EFFECTIVE IF:
THEY CAN SUCCESSFULLY NAVIGATE AROUND
POTENTIAL PITFALLS: 6P’S:

1. PENETRATION
2. PORINS
3. PUMPS - EFFLUX PUMPS
4. PENICILLINASES (really β-lactamases, but that
does not start with P!)
5. PBPs
6. PEPTIDOGLYCAN IS ABSENT
* = β-LACTAM AGENTS (=β-LACTAMS)
β-LACTAMASEs come in many flavors!
the β-lactamase of Staphylococcus aureus is relatively
specific for some of the penicillins.
the extended-spectrum β-lactamases made by some
strains of Escherichia coli and Klebsiella spp. degrade
nearly all penicillins, cephalosporins, and
monobactams.
PENICILLINS
Pictures show Penicillium species, from which penicillins
were derived: Penicillium notatum, P chrysogenum,
Discovery of penicillins
Alexander Fleming: 2 week vacation
Incubation left at room temperature instead
of 37°C
to slow the growth rate of the bacteria
Penicillium grows at room temperature
but not 37°C.

VACATIONS MAKE TRUTHFULLY

PRODUCTIVE AT WORK!
GO ON HOLIDAY
TO MAKE A
DISCOVERY.
Resim eklemek için simgeyi tıklatın a thiazolidine
ring attached to
a β-lactam ring
that is itself
modified by a
variable side
chain (“R” in
Fig.).

6-APA: 6-Aminopenisilanic acid =

β-lactam ring + THIAZOLIDINE RING
THE STRUCTURE OF
PENICILLINS
CHEMICAL STRUCTURE - FUNCTIONS
THİAZOLİDİNE–β-LACTAM : antibacterial activity
SIDE CHAIN: extra pharmacologic activity:
Types (per side chain)
Natural Penicillins
Antistaphylococcal penicillins
Aminopenicillins
Extended-spectrum penicillins
+
Penicillins in combination with β-lactamase
inhibitors
Category Parenteral Agents TR Brands Oral Agents TR Brands

Natural penicillins Penicillin G Penadur ®, Penicillin V Pen-Os ® (Ospen®)*,

Deposilin® Cliacil ®**,

Antistaphylococcal Nafcillin, oxacillin, Dicloxacillin

penicillins (methicillin)

Aminopenicillins Ampicillin Amoxicillin, Alfoxil®, Largopen®***

Alfasilin®, Silina®****
ampicillin

Aminopenicillin + β- Ampicillin- Alfasid®, Amoxicillin- Augmentin®,

Duocid® Amoklavin®, Croxilex®
lactamase inhibitor sulbactam clavulanate

Extended-spectrum Piperacillin, Carbenicillin Geopen®

penicillins ticarcillin

Extended-spectrum Piperacillin-  Tizacin®,

penicillin + β- tazobactam, Timentin®
lactamase inhibitor ticarcillin-
clavulanate

* Penisilin V benzatin, **penisilin V potasyum, ***amoxicillin, **** ampicillin

SCHEMATIC TO UNDERSTAND
EFFICACY

“WALK” SIGN: ACTIVE

“STOP” SIGN: NOT ACTIVE

“CAUTION” SIGN: SOMETIMES ACTIVE

SCHEMATICS TO DERIVE GENERAL
EFFICACY / examples
TO understand clinically what to do with what
bacteria; let’s divide bacteria into four major groups:
Gram-positive, Gram-negative, anaerobes, atypical.
Gram-positive: GO! Use the antibiotic to treat
infection. (ACTIVE)
Gram-negative: STOP! Don’t use the antibiotic.
(NOT ACTIVE).
Anaerobes: PROCEED WITH CAUTION!
(SOMETIMES ACTIVE)
Atypical: PROCEED WITH CAUTION!
(SOMETIMES ACTIVE)
Let us
remember
the Gram
negative
and the
Gram
positive.
NATURAL PENICILLINS
Which is oral and which is parenteral?
RESISTANCE TO NATURAL
PENICILLINS
Some are intrinsically resistant and some have
acquired resistance: Six P’s again: What were the six
P’s?
1. PENETRATION
2. PORINS
3. PUMPS - EFFLUX PUMPS
4. PENICILLINASES (really β-lactamases, but that
does not start with P!)
5. PBPs
6. PEPTIDOGLYCAN IS ABSENT
KNOW THY ENEMY: CHOOSE YOUR
WEAPON
1. Penetration: Rickettsia & Legionella
Penetration—natural penicillins, like most β-lactams,
penetrate poorly into the intracellular compartment of
human cells, so bacteria that for the most part reside in
this compartment, such as
Rickettsia and
Legionella,
are protected from them.
2. Porins
Porins—Some Gram-negative bacteria, such as
Escherichia coli,
Proteus mirabilis,
Salmonella enterica, and
Shigella spp.,
have porins in their outer membranes that do not allow
passage of the hydrophobic natural penicillins to the
periplasmic space.
3. Pumps
Pumps—some Gram-negative bacteria, such as
Pseudomonas aeruginosa,
have efflux pumps that prevent the accumulation of
penicillins within the periplasm. Although these pumps
by themselves may only cause a marginal change in
susceptibility, they can work together with
penicillinases and porins to have a dramatic effect.
4. Penicillinases
Penicillinases—
many bacteria,
both Gram-positive (staphylococci) and
Gram-negative (some Neisseria and Haemophilus
strains, many of the enteric species not listed in [b],
and
some anaerobes, such as Bacteroides fragilis),
make penicillinases that degrade the natural
penicillins.
5. PBPs
Penicillin-binding proteins (PBPs)—some bacteria
produce PBPs that do not bind natural penicillins with
a high affinity (e.g., some strains of
Streptococcus pneumoniae).
6. Peptidoglycan
Peptidoglycan—some bacteria, such as
Mycoplasma and
Chlamydia spp.,
do not make peptidoglycan and therefore are not
affected by the natural penicillins.
Natural Penicillins
can be purified directly from cultures of Penicillium
mold.
R (penicillin G): hydrophobic benzene ring.

Nearly all bacteria’s cell wall consist of peptidoglycan.

Active against:
some species of Gram-positive,
Gram-negative, and
anaerobic bacteria, as well as some spirochetes.
ANTİMİCROBİAL ACTİVİTY OF
NATURAL PENİCİLLİNS
BACTERIA BACTERIA TYPE
Gram-positive bacteria Streptococcus pyogenes
Viridans group streptococci
Some Streptococcus pneumoniae
Some enterococci
Listeria monocytogenes
Gram-negative bacteria Neisseria meningitidis
Some Haemophilus influenzae
Anaerobic bacteria Clostridia spp. (except C. difficile)
Actinomyces israelii

Atypical bacteria Treponema pallidum

Leptospira spp.
Take home lesson!
Even a few Gram-negative bacteria,
such as Neisseria meningitidis and some strains of
Haemophilus influenzae that do not make β-
lactamases, remain susceptible to penicillin.
Let’s remember: Gonna need it in the
upcoming slides.

“WALK” SIGN: ACTIVE

“STOP” SIGN: NOT ACTIVE

“CAUTION” SIGN: SOMETIMES ACTIVE

SCHEMATICS TO DERIVE GENERAL
EFFICACY / examples
Gram-positive: GO! Use the antibiotic to treat
infection. (ACTIVE)

Gram-negative: STOP! Don’t use the

antibiotic. (NOT ACTIVE).

Anaerobes: PROCEED WITH CAUTION!

(SOMETIMES ACTIVE)
Atypical: PROCEED WITH CAUTION!
(SOMETIMES ACTIVE)
 ANTISTAPHYLOCOCCAL
PENICILLINS
PENICILLINASE-RESISTANT PENICILLINS:
NAFCILLIN OXACILLIN DICLOXACILLIN
FLUOXACILLIN CLOXACILLIN

R side chain of nafcillin.

Antistaphylococcal Penicillins
BIG residues on their R side chains that prevent
binding by the staphylococcal β-lactamases.
Thus: penicillinase resistant β-lactam penicillins
TREATS:
Staphylococcus aureus
Staphylococcus epidermidis
BUT CANNOT TREAT:
MRSA: Methicillin-Resistant Staphylococcus aureus
MRSE: Methicillin-Resistant Staphylococcus
epidermidis
Because they can not bind to the PBPs of MRSA and
MRSE.
METHICILLIN? You did not mention that!
an antistaphylococcal penicillin that is no longer
commercially available
Representative of the entire class of antistaphylococcal
penicillins in its spectrum of activity.
less effective than natural penicillins against
STREPTOCOCCI and are usually not used to treat
them.
less effective against ENTEROCOCCI and are usually
not used to treat them.
ANTIMICROBIAL ACTIVITIY OF
ANTISTAPHYLOCOCCAL PENICILLINS
BACTERIA BACTERIA TYPE

Gram-positive bacteria Some Staphylococcus aureus

Some Staphylococcus epidermidis
AMINOPENICILLINS
AMPICILLIN AMOXICILLIN

R side chain of ampicillin

AMINOPENICILLINS
An additional amino group
increases their hydrophilicity
INCREASED HYDROPHILICITY allows them to
pass through the PORINS in the outer membranes of
some enteric Gram-negative rods. Ex:
E. coli, P. mirabilis, S. enterica, and Shigella spp.
ANTİMİCROBİAL ACTİVİTY OF
AMİNOPENİCİLLİNS
BACTERIA BACTERIA TYPE
Gram-positive bacteria Streptococcus pyogenes
Viridans group streptococci
Some Streptococcus pneumoniae
Some enterococci
Listeria monocytogenes
Gram-negative bacteria Neisseria meningitidis
Some Haemophilus influenzae
Some Enterobacteriaceae
Anaerobic bacteria Clostridia spp. (except C. difficile)
Actinomyces israelii

Atypical bacteria:Spirochets Borrelia burgdorferi

Aminopenicillin/β-Lactamase Inhibitor
Combinations
CLAVULANATE and SULBACTAM
Compounds developed to inhibit the β-lactamases of many
Gram-positive and Gram-negative bacteria
structurally similar to PENİCİLLİN and therefore bind β-
lactamases, which results in the inactivation of the β-
lactamases.
Ampicillin-sulbactam / parenteral
(sultamisilin –prodrug) / oral
amoxicillin-clavulanate / oral (parenteral?)*
broaden the antimicrobial spectrum of the aminopenicillins.
*AUGMENTIN I.V.
ANTIMICROBIAL ACTIVITY OF AMINOP. + β-
LACTAMASE INHIBITOR COMBO’S
BACTERIA BACTERIA TYPE
Gram-positive bacteria Some Staphylococcus aureus
Streptococcus pyogenes
Viridans group streptococci
Some Streptococcus pneumoniae
Some enterococci
Listeria monocytogenes
Gram-negative bacteria Neisseria spp.
Some Haemophilus influenzae
MANY Enterobacteriaceae
Anaerobic bacteria Clostridia spp. (except C. difficile)
Actinomyces israelii
Bacteroides spp.
Atypical bacteria: Spirochets Borrelia burgdorferi
EXTENDED SPECTRUM
PENICILLINS
PIPERACILLIN TICARCILlINCARBENICILLIN

Even greater penetration into Gram-negative bacteria than is seen with the
aminopenicillins

R side chain of piperacillin

EXTENDED SPECTRUM PENICILLINS
Even greater penetration into Gram-negative bacteria
than is seen with the aminopenicillins.
Best example: the side chain of piperacillin is polar.
increases its ability to pass through the outer
membrane porins of some Gram-negative bacteria.
Piperacillin gets its name from its side chain, which
contains a piperazine derivative.
Resistance and activity
more resistant to cleavage by Gram-negative β-
lactamases.
more active against Gram-negative bacilli, including
many strains of P. Aeruginosa.
susceptible to the β-lactamases of staphylococci
(unlike natural penicillins!)
modest activity against anaerobes.
piperacillin has the broadest activity.
ANTIMICROBIAL ACTIVITY OF
EXTENDED SPECTRUM PENICILLINS
BACTERIA BACTERIA TYPE
Gram-positive bacteria Streptococcus pyogenes
Viridans group streptococci
Some Streptococcus pneumoniae
Some enterococci
Gram-negative bacteria Neisseria meningitidis
Some Haemophilus influenzae
Some Enterobacteriaceae
Pseudomonas aeruginosa
Anaerobic bacteria Clostridia spp. (except C. difficile)
Bacteroides spp.
Extended-Spectrum Penicillin/β-
Lactamase Inhibitor Combinations
piperacillin-tazobactam and ticarcillin-clavulanate
Ext.Spect. Penicillin/β-Lactamase Inh.
Combinations
Strategy: combine extended-spectrum penicillins with
β-lactamase inhibitors.
piperacillin-tazobactam
ticarcillin-clavulanate
The β-lactamase inhibitors neutralize many of the β-
lactamases that otherwise inactivate the extended-
spectrum penicillins, resulting in a marked
enhancement of their activity.
Activity
activity against most aerobic Gram-positive bacteria
including many β-lactamase–producing staphylococci
most aerobic Gram-negative bacteria
nearly all anaerobic bacteria except Clostridium
difficile
piperacillin-tazobactam has a broader spectrum than
ticarcillin-clavulanate.
ANTIMICROBIAL ACTIVITY OF EXT.D-SPECT.
PENICILLIN + β-LACTAMASE INH. COMBO’S
BACTERIA BACTERIA TYPE
Gram-positive bacteria Some Staphylococcus aureus
Streptococcus pyogenes
Viridans group streptococci
Some Streptococcus pneumoniae
Some enterococci
Listeria monocytogenes
Gram-negative bacteria Neisseria spp.
Haemophilus influenzae
MOST Enterobacteriaceae
Pseudomonas aeruginosa
Anaerobic bacteria Clostridia spp. (except C. difficile)
Bacteroides spp.
TOXICITY / ADVERSE
REACTIONS OF PENICILLINS
Allergy: GENERAL RULE OF THUMB: An estimated 3%–10% of people are allergic to penicillins.
Adverse Reactions: nausea, vomiting, and diarrhea.
Also (less likely): drug fever, rash, serum sickness, interstitial nephritis, hepatotoxicity, neurologic toxicity, and hematologic abnormalities.
HYPERSENSITIVITY: Urticaria, angioedema, and anaphylaxis.
GOLDEN RULE: Persons allergic to one penicillin should be considered allergic to all penicillins, and cross-allergenicity may extend to
other β-lactam antibiotics.
TOXICITY / ADVERSE
REACTIONS
Allergy: GENERAL RULE OF THUMB: An estimated
3%–10% of people are allergic to penicillins.
Adverse Reactions: nausea, vomiting, and diarrhea.
Also (less likely): drug fever, rash, serum sickness,
interstitial nephritis, hepatotoxicity, neurologic toxicity,
and hematologic abnormalities.
HYPERSENSITIVITY: Urticaria, angioedema, and
anaphylaxis.
GOLDEN RULE: Persons allergic to one penicillin
should be considered allergic to all penicillins, and cross-
allergenicity may extend to other β-lactam antibiotics.
SUMMARY OF ACTIVITY OF
PENICILLINS
The antistaphylococcal penicillins are inactive against Gram-
negative bacteria.
The natural penicillins have activity against N. meningitidis and
some strains of H. influenzae, but few other Gram-negative bacteria.
The spectrum of the aminopenicillins is expanded to include these
organisms plus some enteric Gram-negative rods, such as certain
strains of E. coli, P. mirabilis, S. enterica, and Shigella spp., that do
not produce β-lactamases.
The extended-spectrum penicillins are active against even more
enteric Gram-negative rods and, importantly, P. aeruginosa.
Finally, the addition of a β-lactamase inhibitor to an extended-
spectrum penicillin extends this list to include most enteric Gram-
negative bacilli.
MNEMONIC: REMEMBER
CLASS OF MNEMONIC COVERAGE
PENICILLIN
ANTISTAPHYLOCOCC N (Nursing) NONE
AL PENICILLINS
NATURAL NH (Nursing Home) Neisseria meningitidis,
PENICILLINS some Haemophilus
AMINOPENICILLINS NHFE (Nursing Home + few enteric rods
Few Elderly)
EXTENDED NHSEP (Nursing Home +some enteric rods,
SPECTRUM Some Elderly Persons) Pseudomonas aeruginosa
PENICILLINS
EXTENDED- NHMEP (Nursing Home +most enteric rods,
SPECTRUM Most Elderly Persons) Pseudomonas aeruginosa
PENICILLINS + Β-
LACTAMASE
INHIBITOR
CASE STUDY – 48 YEAR OLD
MAN
A 48 – YEAR OLD MAN….
48 years old male with cough
A 48 year old man comest to your pharmacy with a 6 day
history of worsening cough productive of green sputum.
He has had fever and chills.
He complains of pain in the right midback with deep
breathing or coughing.
T=38.1°C (100.5°F), his respiratory rate: 24 breaths per
minute, pulse: 98 beats per minute, blood pressure:
120/75 mmHg, saturation of oxygen: 96 % on room air by
pulse oximetry.
Auscultation of his lungs reveals rales in the right lower-
posterior lung field.
What would you treat him with?
A posterior-to-anterior (PA) and lateral chest x-ray
show a right lower-lobe infiltrate.
A sputum Gram stain reveals Gram (+) cocci.
Consequent sputum and blood culture: Streptococcus
pneumoniae.
How do you treat him?
Describe the factors in choosing appropriate antibiotic
agents.
CEPHALOSPORINS
Resim eklemek için simgeyi tıklatın

CEPHALOSPORINS
Cephalosporium acremonium
Cephalosporins / introduction
fungus Cephalosporium acremonium
source of the first members of this class
Advantageous over penicillins
A lot of combinations of modifications and alterations:
large availability of commercial cephalosporins.
structure
nucleus with two side chains
nucleus is 7-aminocephalosporanic acid
similar to the nucleus of penicillin
β-lactam ring is fused to a six-member dihydrothiazine ring instead of a five-
member thiazolidine ring
Advantages over penicillins
RESISTANCE PRONE: intrinsically more resistant to
cleavage by β-lactamases
MORE AVAILABILITY: two sites, R1 and R2, at
which it can be modified:
large number of cephalosporins commercially available
today.
R1: ANTIBACTERIAL ACTIVITY
R2: PHARMACOKINETICS
modifications of the R1 side chain affect antibacterial
activity and alterations of the R2 side chain are
associated with changes in the pharmacokinetic
properties of these agents
Mechanism of effect
Attach to and inhibit penicillin-binding proteins (PBPs), thereby prevent
the appropriate synthesis of peptidoglycan.
peptidoglycan is a constituent of most bacteria
not active against certain species and strains of bacteria.
Why?
REMEMBER THE SIX P’S:

1. PENETRATION
2. PORINS
3. PUMPS - EFFLUX PUMPS
4. PENICILLINASES (really β-lactamases, but that does not start with
P!)
5. PBPs
6. PEPTIDOGLYCAN IS ABSENT
RESISTANCE TO
CEPHALOSPORINS
1. Penetration—cephalosporins, like most β-lactams,
penetrate poorly into the intracellular compartment
of human cells, so bacteria that for the most part
reside in this compartment, such as Rickettsia and
Legionella, are protected from them.
2/6 Porins
Porins—some Gram-negative bacteria, such as
Pseudomonas aeruginosa, have porins in their outer
membranes that do not allow passage of many
cephalosporins into the periplasmic space.
3/6 Pumps
Pumps—some bacteria, such as P. aeruginosa, use
efflux pumps to remove antibiotics from the
periplasmic space.
4/6 Penicillinases
Penicillinases (actually β-lactamases)—many Gram-
negative bacteria, such as Enterobacter and
Citrobacter spp., make β-lactamases that degrade
many cephalosporins.
5/6 PBPs
PBPs—some bacteria, such as the enterococci and
Listeria monocytogenes, produce PBPs that do not
bind cephalosporins with a high affinity.
6/6 Peptidoglycan
Peptidoglycan—some bacteria, like Mycoplasma and
Chlamydia, do not make peptidoglycan and therefore
are not affected by the cephalosporins.
Generalizations of activity of cephalosporins
1. Each successive generation of agents has broader
activity against aerobic Gram-negative bacteria.
2. With several important exceptions, these agents have
limited activity against anaerobes.
3. The activities of these agents against aerobic Gram-
positive bacteria are variable, but in general the first-
generation agents have the strongest activity against
these bacteria.
 generations
Generation Parenteral Agents Oral Agents
First-generation Cefazolin Cefadroxil, cephalexin

Second-generation Cefotetan,* cefoxitin,* Cefaclor, cefprozil,

cefuroxime cefuroxime axetil,
loracarbef

Third-generation Cefotaxime, ceftazidime, Cefdinir, cefditoren,

ceftizoxime, ceftriaxone cefpodoxime proxetil,
ceftibuten, cefixime

Fourth-generation Cefepime  
 FIRST GENERATION
CEPHALOSPORINS
CEFAZOLIN CEFADROXIL CEPHALEXIN

Structure of cefazolin
Strengths
Activity against aerobic Gram-positive cocci such as
staphylococci and streptococci.
The R1 side chains of these agents protect their β-
lactam rings from cleavage by the staphylococcal β-
lactamase.
As a result, they are useful in the treatment of
infections caused by many strains of Staphylococcus
aureus.

Structure of cefazolin
Shortcomings / All cephalosporins
ALL CEPHALOSPORINS cannot bind the PBPs of
methicillin-resistant S. aureus and methicillin-resistant
Staphylococcus epidermidis or many highly penicillin-
resistant Streptococcus pneumoniae (PRSP).
ALL CEPHALOSPORINS ARE INEFFECTIVE
AGAINST MRSA AND MRSE OR PRSP.
ALL CEPHALOSPORINS also lack activity against
Listeria monocytogenes and the enterococci.
Activity against Gram (-), Anaerobes and
others
Limited activity against aerobic and facultative Gram-
negative bacteria.
No protection from the β-lactamases of most Gram-
negative bacteria.
Some strains of Escherichia coli, Klebsiella
pneumoniae, and Proteus mirabilis are susceptible.
Have moderate to poor activity against anaerobes,
intracellular bacteria, and spirochetes.
Antimicrobial Activity of First Generation
Cephalosporins
BACTERIA BACTERIA TYPE
Gram-positive bacteria Streptococcus pyogenes
Some viridans streptococci
Some Staphylococcus aureus
Some Streptococcus pneumoniae
Gram-negative Some Escherichia coli
bacteria Some Klebsiella pneumoniae
Some Proteus mirabilis
SECOND GENERATION
CEPHALOSPORINS
True cephalosporins. Ex: cefuroxime

The cephamycins: cefotetan and cefoxitin

cefoxitin cefotetan
Common activity of true second generation
ceph. And cephamycines
Second generation cephalosporins are more active
against: aerobic and facultative Gram-negative
bacteria, and:
more potent against E. coli, K. pneumoniae, and P.
mirabilis than first-generation agents.
also active against Neisseria spp., and;
β-lactamase-producing strains of Haemophilus
influenzae (true cephalosporins: cefuroxime).
 CEPHAMYCINS
Parent compound originally isolated
from the bacterium Streptomyces
lactamdurans instead of the fungus
Cephalosporium acremonium.
methoxy group in place of the
hydrogen on the β-lactam ring of the
cephalosporin core.

Streptomyces
sp.
 Why include cephamycines with
cephalosporins?
Pharmacologically and chemically similar agents with
second generation cephalosporin,i.e.; cefuroxime.

cefuroxim
e

cefotetan

cefoxitin
True cephalosporins and cephamycins

Advantage of cefuroxime over cephamycines:

True cephalosporins are as active against the Gram (+)

as first generation cephalosporins.
Cephamycines (cefotetan and cefoxitin) have
LIMITED activity against Gram (+)!
Additional methoxy
 
Additional methoxy: Additional methoxy:
advantage over diminished activity
cefuroxime (at a cost!): against staphylococci
enhanced stability to the and streptococci
β-lactamases of some because of decreased
anaerobes, such as affinity for the PBPs of
Bacteroides fragilis. these bacteria.
Antimicrobial Activity of Second Generation
Cephalosporins
BACTERIA BACTERIA TYPE
Gram-positive bacteria Streptococcus pyogenes
Some viridans streptococci
Some Staphylococcus aureus
Some Streptococcus pneumoniae
True cephalosporins have activity equivalent to first-generation
agents
Cefoxitin and cefotetan have little activity.
Gram-negative bacteria Escherichia coli
Klebsiella pneumoniae
Proteus mirabilis
Haemophilus influenzae
Neisseria spp.
Anaerobic bacteria Cefoxitin and cefotetan have
moderate activity.
THIRD GENERATION
CEPHALOSPORINS
CEFTRIAXONE, CEFOTAXIME, CEFTIZOXIME,
CEFTAZIDIME
3rd Gen
have moderate activity against aerobic Gram-positive
bacteria.
With the exception of ceftizoxime, they inhibit most
strains of penicillin-susceptible S. Pneumoniae.
ceftizoxime is also unique in its ability to inhibit a
significant number of anaerobic bacteria, including many
strains of B. fragilis.
Third-generation cephalosporins are also active against
the spirochete Borrelia burgdorferi.
aminothiazolyl
group
at R1 cefotaxime

İncreased activity Against;

increased penetration E. coli, Klebsiella spp., Proteus

through the bacterial outer spp., Neisseria spp., and H.

influenzae relative to the second-
membrane, generation cephalosporins.
increased affinity for PBPs, Many other strains of the
increased stability in the Enterobacteriaceae, including
presence of some of the Enterobacter spp., Citrobacter
freundii, Providencia spp.,
plasmid-encoded β- Morganella morganii, and
lactamases of aerobic and Serratia spp., also initially show
facultative Gram-negative susceptibility to third-generation
bacteria. cephalosporins.
CAUTION! AmpC β-lactamases!
Enterobacteriaceae harbor chromosomally encoded
inducible AmpC β-lactamases that may allow the
emergence of resistance during treatment.
Therefore; either do not use 3rd gen or use it with an
additional beta-lactamase only if proven susceptible in
vitro.
Activity against P. aeruginosa
carboxypropyl group cefoperazone, also has
dramatically increases appreciable activity
antipseudomonal activity against P. aeruginosa,
decreased affinity for the although it is not as
PBPs of staphylococci. active as ceftazidime.
ceftazidime has enhanced
activity against P.
aeruginosa but limited
activity against S. aureus cefoperazo
ne

ceftazidim
e
ceftriaxone
Long half life: once a day!
Antimicrobial Activity of 3rd Generation
Cephalosporins
BACTERIA BACTERIA TYPE
Gram-positive bacteria Streptococcus pyogenes
Viridans streptococci
Many Streptococcus pneumoniae
Modest activity against
Staphylococcus aureus
Gram-negative bacteria Escherichia coli
Klebsiella pneumoniae
Proteus spp.
Haemophilus influenzae
Neisseria spp.
Some Enterobacteriaceae
Spirochetes Borrelia burgdorferi
FOURTH GENERATION
CEPHALOSPORINS
CHALLENGES
suffer from susceptibility to the chromosomally
encoded inducible AmpC β-lactamases of many of the
Enterobacteriaceae.
activity against P. aeruginosa is gained only at the
expense of diminished antistaphylococcal activity.
CEFEPIME
R1: AMINOTHIAZOLYL
R2: PYRROLIDINE (polar)
 more rapid penetration through the outer membrane of
many Gram-negative bacteria, including P.
aeruginosa.
binds at a high affinity to many of the PBPs of these
bacteria.
relatively resistant to hydrolysis by Gram-negative β-
lactamases, including the chromosomally encoded
inducible AmpC β-lactamases of the
Enterobacteriaceae (?? Clinical controversy!)
Very limited anaerobic activity
Antimicrobial Activity of 4th Generation
Cephalosporins
BACTERIA BACTERIA TYPE
Gram-positive bacteria Streptococcus pyogenes
Viridans streptococci
Many Streptococcus pneumoniae
Modest activity against
Staphylococcus aureus
Gram-negative bacteria Escherichia coli
Klebsiella pneumoniae
Proteus spp.
Haemophilus influenzae
Neisseria spp.
Many other Enterobacteriaceae
Pseudomonas aeruginosa
TOXICITY OF
CEPHALOSPORINS
Rash
Urticaria
anaphylaxis
Toxicity of cephalosporins
RARE SIDE EFFECTS OTHER MORE RARE SE
These are relatively SAFE  reversible neutropenia,
pharmaceuticals.  thrombocytosis,
RARELY: immediate
 hemolysis,
hypersensitivity:
Rash  diarrhea, and
Urticaria  elevated liver function
Anaphylaxis
tests.
Those who developed the
above due to penicillins are
recommended not to use
cephalosporins.
Special toxicity
Cefotetan & cefoperazon 5-10 times
more
Hypoprothrombinemia* acetaldehyde
in blood:
+alcohol => disulfiram Hangover
like effects due to symptoms
emphasized!
methylthiotetrazole
moiety at R2 of these
agents

methylthiotetrazol
e
Brief note: hypoprothrombinemia
Deficiency
of prothrombin (Factor II) results
in impaired blood clotting,
increased physiological risk for
bleeding,
especially in the gastrointestinal
system, cranial vault, and
superficial integumentary system.
Integumentery system: the organ
system that protects the body from
damage, comprising the skin and
its appendages
(including hair, scales, feathers,
and nails).
Brief note: Prothrombin and thrombin
Prothrombin (factor II of the coagulation
cascade) is a critical protein in hemostasis. 
Activated factor Xa converts prothrombin
to thrombin.
Thrombin is a potent protease. Its most
important function is the cleavage of
fibrinogen to create insoluble fibrin. Cross-
linking fibrin monomers stabilize the fibrin
clot. Factor XIIIa, activated by thrombin,
carries out this function.
Decreased levels of prothrombin
(hypoprothrombinemia) leads to
mucocutaneous bleeding and hemorrhage
due to lack of prothrombin.
Brief note: Coagulation cascade
Ceftriaxone & biliary sludge
Excreted by biliary excretion:
High doses: biliary sludge.
Sludge: residual, semi-solid material left from
industrial wastewater, or sewage treatment processes.
Biliary sludge: A mixture of microscopic particulate
matter in bile that occurs when particles of material
precipitate from bile.
Biliary sludge, however, may cause intermittent
symptoms and, on occasion the particles may grow in
size and become larger gallstones: nausea and
vomiting, and Pancreatitis
SUMMARY - CEPHALOSPORINS
Vary in activity.
First-generation agents have STRONG activity
against aerobic Gram-positive bacteria.
Second-generation agents have modest activity against
aerobic Gram-positive, aerobic Gram-negative, and (in
some cases) anaerobic bacteria.
Third-generation agents have STRONG activity
against aerobic Gram-negative bacteria.
Fourth-generation agents have ESPECİALLY
ENHANCED activity against aerobic Gram-negative
bacteria.
Let’s review
1st Gen  Gram (+) and STRONG!
2nd Gen  Gram (+), Gram (-), and some anaerobic
but MODEST.
3rd Gen  Gram (-) and STRONG!
4th Gen  Gram (-) and ESPECIALLY
ENHANCED!
 MNEMONIC : Pain in the neck!
GENERATI MNEMONIC COVERAGE
ON
First PECK Proteus mirabilis
Escherichia coli
Klebsiella pneumoniae
Second PIN NECK + Haemophilus
influenzae
+Neisseria spp.
Third PEN IN NECK + some
Enterobacteriaceae
Fourth PAEN IN NECK + Pseudomonas
WHICH CEPHALOSPORIN TO USE WITH
aeruginosa
WHICH MICROORGANISM? RATIONAL
+ many
DRUG USE.
CARBAPENEMS
THE LAST LINE OF DEFENSE: these guys mean bad
business!
IMIPENEM(/CILASTATIN), MEROPENEM &
ERTAPENEM
Carbapenems
İmipenem + silastatin sodyum
Tienam (flakon i.v. ve i.m.)
Meropenem
Meronem (flakon i.v.)
Ertapenem
Invanz (flakon i.v. ve i.m.)
Doripenem

AZTREONAM
Differences of carbapenems from penicillins:
the structure
1. The sulfur is replaced
by a methylene group.
2. The ring contains a
double bond.

Penicillin structure

Carbapenem structure
Extra activities of carbapenems- WHY?
INCREDIBLE BROAD SPECTRUM OF ACTIVITY!

1. VERY SMALL MOLECULES

1. These molecules are quite small and have charge
characteristics that allow them to utilize special porins in the
outer membrane of Gram-negative bacteria to gain access to
the penicillin-binding proteins (PBPs).
2. BETA-LACTAMASE RESISTANCE
1. Their molecular structure makes them resistant against β-
lactamases
3. AFFINITY TO PBPs of BROAD RANGE OF BACTERIA
SO WHAT?
Because of the aforementioned
three properties, carbapenems
are;

1. Adept at gaining access to

periplasm!
2. resisting destruction by β-
lactamases that reside there,
and
3. binding to PBPs to cause
bacterial cell death.
Resistance
Resistance
Pseudomonas aeruginosa
Mutation of porins:
 Carbapenems can’t go through mutated porins.
Increasing the number of efflux pumps:
 Carbapenems can’t accumulate in the periplasm.

Enterococcus faecium and methicillin-resistant

staphylococci:
produce altered PBPs that do not bind these carbapenems
Some bactaria produce extremely powerful β-
lactamases that are capable of cleaving carbapenems.
 IMIPENEM
Beta lactams
Structural simplicity:
no R1!
Derived from
Streptomyces
cattleya

Carbapenem
structure

imipenem
dehydropeptidase I & CILASTATIN
Rapidly destroys imipenem in the kidney because of
lack of R1 in its structure.
Therein comes CILASTATIN

cilastati
n

imipene
m

CILASTATI
N
IMIPENEM + CILASTATIN
Administered together to inhibit dehydropeptidase I from metabolizing
imipenem.
Active against many species of pathogenic bacteria!
Most Streptococci: including Penicillin resistant Streptococcus
pneumoniae.
Most Staphylococcus
But not against MRSA!
Many Gram negative
P. aeruginosa
the highly resistant Enterobacteriaceae
Enterobacter, Citrobacter
excellent anaerobic coverage
But not against Clostridium difficile!
Activity summary
Active against most bacteria resistant
to penicillins and cephalosporins.
Wide antibacterial spectrum
Surpasses activity of 3rd Gen
Cephalosporins.
Not active against MRSA!
JUST LIKE ALL OTHER BETA
LACTAMS!
İmipenem + Silastatin Sodyum- Endikasyon
(i.v.) (ÜLKEMİZDE)

Alt solunum yolu enf. İdrar yolu enf.

Staphylococcus aureus, Enterococcus faecalis,
Escherichia coli, S. aureus,
Klebsiella sp., E. coli,
Enterobacter sp.,
Klebsiella sp.,
Haemophilus
Enterobacter sp.,
influenzae,
Haemophilus Proteus vulgaris,
parainfluenzae, Providencia rettgeri,
Acinetobacter sp., Morganella morganii
Serratia marcescens. P. aeruginosa.
İmipenem + Silastatin Sodyum- Endikasyon
(i.v.) (ÜLKEMİZDE)

Karın içi enf.

Enterococcus faecalis, Citrobacter sp.,
S. aureus, Clostridium sp.,
Staphylococcus epidermidis, Bacteroides sp. (B. fragilis
E. coli, dahil)
Fusobacterium sp.,
Klebsiella sp.,
Peptococcus sp.,
Enterobacter sp.,
Peptostreptococcus sp.,
Proteus sp.,
Eubacterium sp.,
Morganella morganii,
Propionibacterium sp.,
P. aeruginosa
Bifidobacterium sp.
İmipenem + Silastatin Sodyum- Endikasyon
(i.v.) (ÜLKEMİZDE)

Kadın hastalıkları ile ilgili

Enterococcus faecalis; Enterobacter sp.,
S. aureus, Bifidobacterium sp.,
S. epidermidis, Bacteroides sp. (B.
Streptococcus fragilis dahil)
agalactiae (group B Gardnerella vaginalis;
streptococcus), Peptococcus sp.,
E. coli , Peptostreptococcus sp.,
Klebsiella sp., Propionibacterium sp.
Proteus sp.
MEROPENEM
Resistant to dehydropeptidase I: R1 has a methyl
group.
spectrum of activity is essentially the same as
imipenem.
ERTAPENEM
not cleaved by renal dehydropeptidase because of
methyl in R1 (just like imipenem).
R2 side chain: is less active against aerobic Gram-
positive bacteria, P. aeruginosa, and Acinetobacter
spp. than the other carbapenems!
Once a day.
CARBAPENEMS AND
ADVERSE EVENTS.
Nausea, vomiting, diarrhea, rash,
and drug fever
Seizures
Contra-ind: pre-existing central
nervous system disease and with
renal insufficiency
Antimicrobial Activity of CARBAPENEMS
BACTERIA BACTERIA TYPE
Gram-positive bacteria Streptococcus pyogenes
Viridans group streptococci
Streptococcus pneumoniae
Modest activity against Staphylococcus
aureus
Some enterococci
Listeria monocytogenes
Gram-negative bacteria Haemophilus influenzae
Neisseria spp.
Enterobacteriaceae
Pseudomonas aeruginosa

Anaerobic bacteria Bacteroides fragilis

Most other anaerobes
Faecium or faecalis?
Strains of Enterococcus faecalis that are
susceptible to penicillin are also
susceptible to carbapenems
 (except ertapenem).
Enterococcus faecium, however, is
resistant to all carbapenems!
MONOBACTAMS
The lonely cowboy: aztreonam. DOES ONLY ONE THING
BUT DOES IT VERY WELL!
 AZACTAM (artık

AZTREONAM ithal edilmiyor)

kills aerobic Gram-

CEFOTAXI
negative bacteria. ME
the aminothiazolyl
group that so
dramatically improves
the aerobic Gram-
negative coverage of
third-generation
cephalosporins. AZTREONAM
Aminothiazolyl group & aztreonam
Binds quite well to the penicillin-binding proteins
(PBPs) of aerobic Gram-negative bacteria.
stable against many of the β-lactamases.
excellent activity against Neisseria and Haemophilus
spp.
intermediate activity against Pseudomonas aeruginosa

Pseudomonas Haemophilus Neisseria meningitidis

aeruginosa influenzae as seen in
a Gram (-)
technique
Some shortcomings…
does not bind the PBPs of Gram-positive or anaerobic
bacteria.
Can not cure infections by Gram (+) or anaerobic
bacteria.
Resistance: the Enterobacteriaceae and P. aeruginosa
changes in the permeability of the outer membrane
destruction by β-lactamases

Pseudomonas
aeruginosa
Toxicity
Aztreonam is very safe:
NOT associated with nephrotoxicity.
a renal-sparing alternative to the aminoglycosides
(both against Gram negative bacteria).
Penicillin allergies?
Safe to use aztreonam in patients with penicillin
allergies.
Antimicrobial Activity of Aztreonam

BACTERIA BACTERIA TYPE

Gram-negative bacteria Haemophilus influenzae
Neisseria spp.
Most Enterobacteriaceae
Many Pseudomonas aeruginosa
VANCOMYCIN
History
discovered when a “missionary” from
Borneo sent a soil sample to his friend,
who was an organic chemist at “Eli Lilly
and Company.”
The soil sample “turned out” to harbor a
bacterium that made a compound
with potent activity against Gram-positive
bacteria.
Eventually the compound was purified
and named vancomycin, which is derived
from the word “vanquish.”
Ref: Griffith RS. Vancomycin use—an historical
review. J Antimicrob Chemother 1984;14(Suppl
D):1–5.
Structure of vancomycin
A glycopeptide! Not a beta-lactam. a peptide with
sugar moieties attached to it.
Intact peptides are poorly absorbed in the GI tract.
Its structure helps it to bind!
Similarity to beta lactams: preventing synthesis of the
cell wall.
binds to the D-alanyl-D-alanine portion of the peptide
side chain of precursor peptidoglycan subunits.
Mechanism of penicillin-binding protein
(PBP) inhibition by β-lactam antibiotics.
A. PBPs recognize and
catalyze the peptide bond
between two alanine
subunits of the
peptidoglycan peptide
side chain. B. The β-
lactam ring mimics this
peptide bond. Thus, the
PBPs attempt to catalyze
the β-lactam ring,
resulting in inactivation
of the PBPs.
Bulky molecule!
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).
A glycopeptide
poorly absorbed in the gastrointestinal
tract: only i.v forms available.
Clostridium difficile: effective against
diarrhea by C. difficile.
ONLY ORAL FORMS – not absorbed thru
GI track, that’s why!
Not able to pass through PORINS: not
effective against Gram (-)
But very effective against Gram (+).

Question: Can you name an antibiotic

which is the opposite?

Clostridium difficile associated

collitis
Active against:
nearly all staphylococci and
streptococci, including methicillin-
resistant staphylococci and strains of
penicillin-resistant Streptococcus
pneumoniae. Streptococcus
pneumoniae
Listeria monocytogenes: susceptible
in vitro but not so much in vivo!
CAUTION!
good activity against anaerobic Gram- Listeria
monocytogenes
positive bacteria, including C.
difficile.
C. difficile
Antimicrobial Activity of Vancomycin
BACTERIA BACTERIA TYPE
Gram-positive bacteria Staphylococcus aureus (CAUTION!)
Staphylococcus epidermidis
Streptococcus pyogenes
Viridans group streptococci
Streptococcus pneumoniae
Some enterococci (except VRE)

Anaerobic bacteria Clostridium spp.

Other Gram-positive anaerobes
RESISTANCE: VRE
Vancomycin Resistant Enterococci (VRE): 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.
Gene transfer S. aureus
Unfortunately, the gene clusters that encode this
activity in enterococci are transferable and have
already been found in Staphylococcus aureus. Thus, it
is anticipated that vancomycin resistance will occur
with increasing frequency in staphylococci as well.
Toxicity
Hearing loss – esp. w/
aminoglycosides
Red man syndrome
develop pruritus and an
erythematous rash on the face,
neck, and upper torso.
Neutropenia: dangerously or
abnormally low count of
neutrophils in the blood
stream.
Atypical white blood cell count per cubic mm of blood should be be neutrophils
– 3650, monocytes – 430, lymphocytes – 2500, eosinophils – 150 and basophils
– 30. Neutrophils kill and absorb invasive microorganisms. Neutropenia occurs
when the neutrophils count measures less than 2000 cells per cubic mm. 
Resim eklemek için simgeyi tıklatın

DAPTOMYCIN
a novel cyclic lipopeptide antibiotic
Daptomycine – the first of a new class
First of a new class: THE CYCLIC LIPOPEPTIDES
Rapidly bactericidal-concentration dependent.
Active against Gram(+) pathogens.
Unique mode of action.
No cross-resistance with other antimicrobial classes!
90% protein (92% albumin) bound.
Once a daily IV
Poor efficacy in pulmonary infections.
RESISTANCE reported! (during clinical trials
PHASE II)
E faecalis, S aureus, and among clinical isolates of
MRSA
Chemical structure
The lipophilic tail: lipid portion of
this drug inserts into the bacterial
cytoplasmic membrane, where it
forms an ion-conducting channel.
Ions escape from the bacterium.
Bacterium dies.

Daptomycin is a 13-member amino acid cyclic lipopeptide compound that contains a

water-soluble hydrophilic core with a lipophilic tail. The lipophilic tail exerts itself into
the cytoplasmic membrane of the gram-positive cell wall.
Mechanism of action
The acyl tail  inserts itself into the cytoplasmic
membrane.
forms a channel that causes depolarization of the
membrane. 
efflux of potassium (and possibly other) cytoplasmic
ions, thus inhibiting macromolecular synthesis and
leading to cell death.
Peculiarity: Stealth!
Concentration dependent.
Rapid.
Unlike that of many other antibiotics.
Depolarization of acyl tail is correlated with
daptomycin's bactericidal activity.
Why stealth? Leaves a ghost cell behind – completely
drained.
But daptomycin DOES NOT rupture the cell wall!
Activity
Unfortunately not active
Active against: against:
many aerobic Gram-positive Gram-negative
bacteria,
organisms
including highly resistant
Cannot reach the
strains such as
methicillin-resistant cytoplasmic membrane
Staphylococcus aureus, through the Gram(-)
penicillin-resistant outer membrane.
Streptococcus pneumoniae, and Pneumonia: poor
some vancomycin-resistant
activity in lungs!
enterococci!
Pulmoner sürfaktan
GREAT!
tarafından
etkisizleştirilir.
Ek note: Pulmoner sürfaktan nedir?
Akciğer sıvılarının yüzey gerilimlerini azaltarak solunum
yollarının açık kalmasını sağlamaya yardımcı olan doğal
maddelere benzeyen yüzey aktif bileşiklerdir.
Eksojen pulmoner surfaktanlar, prematüre bebeklerde
neonatal solunum sıkıntısı sendromunda 100 – 200 mg
fosfolipit / kg (doğum ağırlığı) olarak, ilk doz teşhisten
sonra en kısa zamanda uygulanır. Entübe bebeklerde
endotrakeal tüp vasıtasıyla mekanik solunuma solüsyon
olarak verilebilir.
Başlıcaları: beraktant, kolfoseril palmitat, poraktan alfa, sığır
akciğer sürfaktanı fosfolipid fraksiyonu, kalfaktan,
lusinaktan, pumaktant, sinapultit
Pulmoner sürfaktanlar neden daptomycin’i
tutarlar?
Bunların yapısında iki temel yapı vardır:
Fosfatidilgliserol
Dipalmitoilfosfatidilkolin
Bu iki madde Gram (+) hücre membranında da vardır!
Daptomycin bu maddelerin içine girer, hapsolur ve
etkisini gösteremez.
Antimicrobial Activity of Daptomycin
BACTERIA BACTERIA TYPE
Gram-positive bacteria Streptococcus pyogenes
Viridans group streptococci
Streptococcus pneumoniae
Staphylococci
Enterococci

Anaerobic bacteria Some Clostridium spp.

Clostridium difficile, Clostridium
perfringens,
General Indication
Primarily used for:
SKIN
SOFT TISSUE
infections.

approved in 2003 in the U.S. for the treatment of complicated

SSSIs caused by S. aureus, including MRSA, as well as
Streptococcus pyogenes, Streptococcus agalactiae, Streptococcus
dysgalactiae subsp. equisimilis, and Enterococcus faecalis
(vancomycin-susceptible isolates only). Recently, the label for
daptomycin was extended to include the treatment of bacteremia,
including right-sided endocarditis caused by S. aureus.*
* Cubist Pharmaceuticals. Cubicin® (daptomycin for injection) prescribing
information. 2006. Lexington, MA. 
Why do we need daptomycin?
MRSA: First choice of treatment is
VANCOMYCIN, but
Needs monitoring of dosages &
Can cause nephrotoxicity!
RESISTANCE!
vancomycin-resistant S. aureus (VRSA) 
vancomycin-resistant enterococci (VRE)
vancomycin-intermediate S. aureus (VISA) 
Commonly used linezolid’s disadvantage:
one may need to limit the duration of therapy due to
hematologic adverse events (suppression of blood cell counts).
Dis- and Advantages of daptomycin
Adv Disadv
No other agent detected or Effectiveness is
known (yet?!) that is resistant. dependent on free
There is very little data of
losing susceptibility.* biologic calcium.
No other agent detected or To let the efflux of K+
known that cause trans- Effectiveness can be
resistance (like the VRE from hindered by albumin
VRS aureus).
Once a daily dose
concentrations.
Less renal deficiency Dose dependence and
causing** combinations still under
investigation.
Toxicity
Relatively safe and well tolerated.
High doses  reversible myopathy.
Phlebitis
Rash
GI intolerance