INTRODUCTION TO

CHEMOTHERAPY & cell wall

synthesis inhibitors

Dr. Maria Khurshid

Antibiotics

 Any chemical substance obtained from microorganism which selectively suppress the
growth or kill other microorganism at very low conc.

 CHEMOTHERAPY:
 Treatment of infectious diseases or malignancy with drugs which destroy microorganism
or cancer cells with minimal damage for host cells.
1. Bacteriostatic versus bactericidal drugs

 bacteriostatic drugs were thought to only arrest the

growth and replication of bacteria at drug levels
achievable in the patient,
 bactericidal drugs were able to effectively kill
≥99.9% (3-log reduction) within 18 to 24 hours of
incubation under specific laboratory conditions.
2. Minimum inhibitory concentration

 The minimum inhibitory concentration (MIC) is

the lowest antimicrobial concentration that
prevents visible growth of an organism after 24
hours of incubation.
 This serves as a quantitative measure of in vitro
susceptibility
3. Minimum bactericidal concentration:

 The minimum bactericidal concentration (MBC) is

the lowest concentration of antimicrobial agent
that results in a 99.9% decline in colony count
after overnight broth dilution incubations
 IV. Determinants of Rational Dosing

 Concentrationdependent killing,: Certain

antimicrobial agents, show a significant increase in
the rate of bacterial killing as the concentration of
antibiotic increases from 4- to 64-fold the MIC of
the drug for the infecting organism
 time-dependent (concentration-independent) killing,
 and postantibiotic effect (PAE).
B. Time-dependent (concentration-
independent) killing
 The clinical efficacy of these antimicrobials is best
predicted by the percentage of time that blood
concentrations of a drug remain above the MIC.
This effect is sometimes called time-dependent
killing.
C. Postantibiotic effect

 The PAE is a persistent suppression of

microbial growth that occurs after levels of
antibiotic have fallen below the MIC.
 V. Chemotherapeutic Spectra

 A. Narrow-spectrum antibiotics:
isoniazid
 B. Extended-spectrum antibiotics
ampicillin
 C. Broad-spectrum antibiotics
tetracycline, fluoroquinolones
carbapenems
VII. Drug Resistance

 A. Genetic alterations leading to drug resistance

 Acquired antibiotic resistance requires the temporary or
permanent gain or alteration of bacterial genetic
information.
 Resistance develops due to the ability of DNA to undergo
spontaneous mutation or to move from one organism to
another
B. Altered expression of proteins in drug-
resistant organisms
 1. Modification of target sites : S. pneumoniae resistance
to β-lactam antibiotics involves alterations in one or more
of the major bacterial penicillin-binding proteins
 2. Decreased accumulation: ↓uptake or ↑ efflux
 3. Enzymatic inactivation : 1) β-lactamases
(“penicillinases”) 2) acetyltransferases inactivating
chloramphenicol or aminoglycosides;
 3) esterases that hydrolyze the lactone ring of macrolides.
Complications of Antibiotic Therapy

 A. Hypersensitivity
 B. Direct toxicity
 C. Superinfections
Sites of Antimicrobial Action
Obtained from
 Penicillium notatum (Early)
 Penicillium chrysogenum (Now, Better Yield)
 The penicillins share features of
 chemistry, mechanism of action, pharmacology, and immunologic characteristics
 with cephalosporins, monobactams, carbapenems, and β-lactamase inhibitors.
 All are β-lactam compounds,
 so named because of their four membered lactam ring.
Chemistry

 All penicillins have the basic structure

 thiazolidine ring (A) is attached to
 a β-lactam ring (B) that carries
 a secondary amino group (RNH–).
 Substituents can be attached to the amino group.
 Structural integrity of the 6-aminopenicillanic acid nucleus (rings
 A plus B) is essential for the biologic activity of these compounds.
 Hydrolysis of the β-lactam ring by bacterial β-lactamases yields
 penicilloic acid, which lacks antibacterial activity.
 Chemistry
•Penicillin nucleus consists of
• Thiazolidine ring (Ring A)-
• Sulphur containing with COOH (Carboxyl group),
• Beta lactam ring (Ring B) – (Broken by Betalactamase)
• Side chain is attached at position – 6- (NHCOR)

•Side chains attached through amide linkage. (Broken by

Amidase)
 Beta Lactam ring is broken by –
• Penicillinase (Beta Lactamase), and by gastric acid.

Resultant Product is Penicilloic acid with
 No anti-bacterial activity but
 Acts as antigenic determinant (Major determinant stimulate immune response of the body)

 Penicillins are available as

• Na+ or K+ salts .
• Amine salts such as Procaine and Benzathine Penicillin.
Broken by Amidase enzyme

Active material
Raw material for other
penicillin

Broken by Betalactamase enzyme

Inactive
Responsible for
hypersensitivity
Active material Inactive (Major Determinant)
Raw material for other Responsible for
penicillin hypersensitivity
 Penicillin Cephalosporins

Carbapenem Monobactam

Beta Lactamase inhibitor (Claulanic acid and Sulbactam)

Suicide Inhibitors Beta Lactamase
 MOA
•Bacteria are unique
• Don’t have osmotic regulating mechanism
• Cell wall controls osmotic changes.

•Cell wall is composed of

• Peptidoglycans
• Cross linked by peptide chains.
• NAM – NAG ( N-acetyl muramic acid and N- acetyl glucosamine)
• Cross linked by a Pentaglycine cross bridge
(Extending from the L-lysine residue of one peptide chain to the D-
alanine residue of another peptide chain).
Betalactam
Antibiotics
 Cross bridging is transpeptidation reaction.

 Transpeptidase and related proteins (Penicillin Binding Proteins) are used for
making cross linkage in Bacterial cell wall.

 Cross linking provides stability, strength.

•β-Lactams inhibit Transpeptidase leading to
• Damage of cross linking
• Weakening of cell wall
• Swelling of cell due to Endosmosis
• Bacterial membrane bursts
• Bacterial lysis

•Additional mechanism –
• Activation of autolysing enzymes
(Murein Hydrolase and Autolysins)

•More lethal during active multiplication

 (Benzyl)
Lack porins

Hydrophilic
Aqua porins

Benzathine penicillin and

procaine penicillin G , I/M
form low yield but prolong
drug
 Bactericidal activity of penicillin is more against Gram positive. (Difference in
organization of cell wall)

 In gram positive
• Thick layer of Peptidoglycans and teichoic acid (a polyol phosphate polymer)
surrounds the membrane.
• Peptidoglycans layer is easily accessible to Beta lactam antibiotics

 In gram negative
• Two membranes are present. (The cytoplasmic membrane and an outer
membrane with thin layer of Peptidoglycans sandwiched between the two).
• The outer membrane consists of lipopolysaccharides with narrow porin
channels which function as a barrier to permeability of antibiotics
38
Peculiarities of penicillins

 The greatest effect on gram-positive (G+)

microorganisms, their cellular wall contains from 40 to
90% of peptidoglycans
(gram-negative (G-) ones – only 5%).
 The effect is only to divisible cells because the growing
microbial cells need the material to build the cellular wall.
 A low toxicity; cheapness.
 A broad spectrum of the therapeutic action.
 A good absorption, distribution and penetration into
tissues.
 Cross-allergy between all penicillins and cephalosporins
and carbapenems in part.
 Resistance against Penicillin
•By four mechanisms
•(1) inactivation of antibiotic by β-lactamase,
•(2) modification of target PBPs,
•(3) impaired penetration of drug to target PBPs,
•(4) antibiotic efflux.

•Natural
• Target enzymes and PBPs are deeply located (Lipoprotein barrier in –ve)
• PBPs of organisms have low affinity for penicillin

•Acquired
• Production of Penicillinase (Beta-Lactamase) enzyme, (>300 subtypes).
• Common organisms producing Beta-Lactamase are
• Staphylococcus
• Bacillus subtilis
• Gonococci
• E. coli
• Enterococci
• Haemophilus influenza
• Loss or alteration of Porin channels in gram negative
• Modification of penicillin binding proteins (PBPs)- having low affinity .
• Activation of antibiotic efflux mechanism- Some gram negative bacteria
 Adverse effects
•General
•Hypersensitivity reactions (including Anaphylaxis)

More with procaine penicillin,

Intradermal Skin sensitivity test

Major Determinant (Penicilloyl moiety in terms of amount) is

responsible for hypersensitivity other than anaphylaxis

Minor determinants( Penicillamine and Penicillenate) are

responsible for anaphylaxis.

The Penicilloyl moiety or major determinant results from reaction of beta-lactam

ring with endogenous proteins. The Beta lactam ring spontaneously opens in the
body forming a hapten-protein complex, the most abundant but not necessarily
most immunogenic.
Hypersensitivity testing
Drug Interactions
 With Tetracyclines, Chloramphenicol, Erythromycin-
 Antagonism
 Penicillin with Aminoglycosides-
 Synergism.
 Penicillin and Aminoglycosides or Penicillin and hydrocortisone in same syringe –
 Inactivate each other (Pharmaceutical)
 Ampicillin with Allopurinol –
 High incidence of non-urticarial maculopapular rashes
 Penicillin with Probenecid
 Prolongs action of penicillin by decreasing tubular secretion
Therapeutic
uses
Kinetics
 MONOBACTAMS
• drugs with a monocyclic β-lactam ring
• no activity against gram-positive bacteria or anaerobes

Aztreonam
• resistant to beta-lactmases

Antibacterial action
Gram negative aerobic bacteria eg pseudomonas
Pharmacokinetics
• Administration……IV
• elimination
renal tubular secretion.
• half-life … inc in renal failure.
Adverse effects
• gastrointestinal upset
• superinfection,
• vertigo
• Headache
• Rare….. hepatotoxicity.
• skin rash
Cross allergenicity
• no cross-allergenicity with penicillins and cephalosporins except
ceftazidime.
USE
• In pts with history of pencillin allergy
• Pneumonia,menenigitis,sepsis
 CARBAPENEMS
(chemically different from penicillins but retain the beta-lactam ring structure)
susceptibility to beta-lactamases…low

Antibacterial acitvity
• gram-positive cocci (including some penicillin-resistant
pneumococci),
• gram-negative rods,
• anaerobes.(P aeruginosa and Acinobacter species)
• Enterobacter infection that are beta lactamase resistant
USE IN PSEUDOMONAL INFECTIONS
• used in combination with an aminoglycoside
• infections caused by organisms resistant to other antibiotics

RESISTANCE
MRSA strains of staphylococci are resistant

ADMINISTRATION
Parenterally

CO-DRUGS OF CHOICE for

Enterobacter, Citrobacter, and Serratia species infections
 Imipenem

rapid inactivation by renal dehydropeptidase I

Administered
• fixed combination with cilastatin(inhibitor of renal dehydropeptidase I)

REASON
• Cilastatin increases the plasma halflife of imipenem
• inhibits the formation of a potentially nephrotoxic metabolite.
Adverse effects of Imipenem-Cilastatin
• Gastrointestinal distress,
• skin rash,
• CNS toxicity(confusion, encephalopathy,
seizures).
• partial crossallergenicity with the penicillins
 Meropenem
• similar to imipenem
• except that it is not metabolized by renal dehydropeptidases
• seizures(LESS LIKELY)

Ertapenem
• long half-life
• less active against enterocci and Pseudomonas
• Intramuscular injection causes pain and irritation.
BETA-LACTAMASE INHIBITORS(WEAK ANTIBIOTICS)

• Clavulanic acid,
• Sulbactam,
• Tazobactam

used
fixed combinations with certain hydrolyzable penicillins.
Antibacterial activity
• plasmid-encoded beta-lactamases such as those produced
by gonococci, streptococci, E coli, and H influenza

• not good inhibitors of inducible chromosomal beta-lactamases

formed by
• Enterobacter
• Pseudomonas
• Serratia.
OTHER CELL WALL
OR MEMBRANE-
ACTIVE AGENTS
 VANCOMYCIN
• bactericidal glycoprotein …..binds to peptidoglycan side chain
• inhibits transglycosylation
• Prevents elongation of the peptidoglycan chain and interferes with
crosslinking.
RESISTANCE
• strains of enterocci (vancomycin-resistant
enterococci [VRE])
• staphylococci (vancomycin-resistant-S aureus [VRSA])
Reason
• decreased affinity for the binding site(of the replacement of the terminal
d-Ala by d-lactate)
Adverse effects
neurotoxicity
tremors,
• seizures,
• Psychosis
Keep oral dose below
0.75g/da
Antibacterial activity
• narrow
• serious infections caused by drug-resistant gram-positive
• organisms
• methicillin-resistant staphylococci (MRSA)
• infections due to penicillin-resistant pneumococci (PRSP) (in
combination with a third-generation cephalosporin such as ceftriaxone)
• infections caused by Clostridium difficile
(back-up drug)
 Clinical uses
Blood stream infections and endocarditis caused by
• MRSA
• Methicillin succeptible strains

Vancomycin + gentamycin
Enterococcal endocarditis in patients with pencilin allergy

Vancomycin+cefotaxime
Meningitis treatment

Oral
Treat colitis caused by clostridium difficile
Resistance
• Vancomycin-resistant enterococci(can use Dalbavancin and
Oritavancin)
• Vancomycin resitant staph aureus

Pharmacokinetics
• not absorbed from gastrointestinal tract
• given orally for bacterial enterocolitis.

parenterally,
• penetrates most tissues
• eliminated unchanged in the urine.
Toxic effects of vancomycin
• chills
• fever
• Phlebitis
• ototoxicity
• Nephrotoxicity
• Rapid intravenous infusion may cause diffuse flushing (“red man
syndrome”)from histamine release.
Teicoplanin
• MOA like that of vancomycin

Telavancin
• MOA like that of vancomycin & inc permeability and disrupts cell wall
membrane
Use
• Skin and soft tissue infections
• Hospital acquired pneumonia
Adverse effects
Teratogenecity
nephrotoxic
 FOSFOMYCIN

• antimetabolite inhibitor of cytosolic enolpyruvate Transferase

• prevents the formation of N-acetylmuramic acid( essential precursor
molecule for peptidoglycan chain formation)

Resistance reason
• Dec transport of drug in cell
• decreased intracellular accumulation of the drug.
Pharmacokinetics
• excreted by the kidney

In a single dose
• it is less effective than a 7-day course of treatment with fluoroquinolones

multiple dosing,
• resistance emerges rapidly
• diarrhea

synergistic with beta-lactam and

quinolone antibiotics in specific infections.
Antibacterial action
Gram positive and gram negative bacteria

Clinical use
Treatment of urinary tract infections
 BACITRACIN
peptide antibiotic

Mechanism of action
• interferes with a late stage in cell wall synthesis in gram-positive organisms.

Adverse effects
• marked nephrotoxicity

use
• Used only topically for skin or mucosal membrane lesions
 CYCLOSERINE

Antimetabolite
Water soluble
unstable at acidic pH
Widely distributed in tissues

Mechanism of action
blocks the incorporation of d-Ala into the pentapeptide side chain of the
peptidoglycan.
Spectrum of action
• only for tuberculosis caused by organisms resistant to first-line
antituberculous drugs.

Adverse effects
neurotoxicity
tremors,
• seizures,
• Psychosis
Keep oral dose below 0.75g/day
 Daptomycin

cyclic lipopeptide

Spectrum of action
with spectrum similar to vancomycin but active against vancomycin-resistant
strains of enterococci and staphylococci.

Pharmacokinetic
eliminated via the kidneyma

Moniter
Creatanine phohphokinase( daptomycin causes mayopathy)
Antibacterial activity
• Treatment of skin and soft tissue infections
• Treatment of bacteremia and endocarditis