Antibiotics

Antibiotics and vaccines are among the biggest

medical advances since 1000. (Culver Pictures)

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 A brief history of antibiotics
 1495, mercury to treat syphilis.
 1630, quinine (chinchona tree) for malarial fever by South Americ
an Indians.
 1889, Buillemin defined antibiosis.
 1910, Paul Ehrlich developed arsenical compound (Salvarsan) for
syphilis, term: the chemical knife.
 1929, Alexander Fleming found penicillin.
 1935, Gerhard Domagk showed the value of sulfonamides.
 1940, Ernst Chain and Howard Flory demonstrated the effect of p
enicillin.
 1940-1970, then searching for new antibiotics
 ~ recent year: modifying old drugs, finding new discipline in antib
acterial combats
 Early time in war: thanks penicillin, we can go home now
 Now a day……….Oh eh?!

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 Thanks to work by Alexander Fleming (1881-
1955), Howard Florey ( 1898-1968) and Ernst
Chain (1906-1979), penicillin was first produced
on a large scale for human use in 1943. At this
time, the development of a pill that could reliably
kill bacteria was a remarkable development and
many lives were saved during World War II
because this medication was available.

A. Fleming E. Chain H. Florey

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 A tale by A. Fleming
• He took a sample of the
mold from the contamina
ted plate. He found that it
was from the penicillium
family, later specified as
Penicillium notatum. Fle
ming presented his findin
gs in 1929, but they raise
d little interest. He publis
hed a report on penicillin
and its potential uses in t
he British Journal of Exp
erimental Pathology.

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 Scenario of penicillin action on E. coli
1 2 3

6 5 4

1: ordinary appearance
2-4: globular extrusions emerge
5: rabbit-ear forms
6: Ghost form

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 Natural products, including: toxins, antibiotics (about 70% of all
known antibiotics) , antifungals, etc, have historically been
isolated and characterized from heterotrophic bacteria (e.g.
Streptomyces). This was primarily due to the ease with which
these organisms can be grown and manipulated in the laboratory.

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 Evaluation by BUSINESS COMMUNICATIONS COMPANY, INC.,

In 2001, the problem of antimicrobial resistance posed a global threat to

the effective treatment of many bacterial diseases. In developed
countries, as many as 60% of hospital-acquired infections are caused by
drug-resistant microbes. These infections are no longer found only in
hospital or nursing home wards but are active in the community at large.

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 An ideal antibiotics
 Broad-spectrum
 Did not induce resistance
 Selective toxicity, low side effects
 Preserve normal microbial flora

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 Susceptibility test
 Tube dilution method
 Minimal inhibitory conce
ntration (MIC): the small
est amount of chemothera
peutic agent required to i
nhibit the growth of orga
nism in vitro
 Disk diffusion method
 Zone of inhibition (ZOI):
the correlation of ZOI an
d MIC has been establishe
d by FAD

ETest. This commercially-prepared strip creates

a gradient of antibiotic concentration when
placed on an agar plate
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 Guidance of antimicrobial therapy
 Minimum inhibitory concentration: lowest conc
entration of antibiotic that inhibits visible growth
 Minimum bactericidal concentration: lowest co
ncentration of antibiotic that kills 99.9% of the ino
culum
 Serum bactericidal title: dilution of serum that ki
lls 99.9% of the inoculum
 Synergy test: synergistic activity of multiple antib
iotics

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 Use of antibiotics; is it properly applied?
 Acute infections in outpatients
 Acute infections in hospitalized patients
 Chronic infection (tuberculosis, AIDS)
 Agriculture/veterinary medicine

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 In vitro: Factors for optimal antibiotic action
 pH of environment:
 Nitrofurantoin is more active in acid pH; sulfonamides and
aminoglycoside are more active in alkaline pH.
 Components of medium:
 Anionic detergents inhibit aminoglycosides, serum proteins
bind to penicillin in varying degrees.
 Stability of drug:
 Aminoglycosides and chloramphenical are stable for long p
eriod in vivo.
 Size of inoculums:
 The larger the bacterial inoculum, the greater the chance fo
r resistnat mutant to emerge.
 Metablic activity of microorganisms:
 Actively and rapidly growing organisms are more susceptib
le to drug action

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 Affecting factors in vivo

 Abscess: circulation is blocked off.

 Foreign bodies: obstruction of the ur
inary, biliary or respiratory tracts et
c.
 Immunity.

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 Diagrammatic representation of the results of
treatment related to specific chemotherapy
Patients with normal immunity Patients with serious life-
and uncomplicated mild to threatening infections
moderate infections

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 Sites of action

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 Modes of action (1)
 Inhibitors of cell wall synthesis.
Penicillins, cephalosporin, bacitracin, carbapen
vancomycin
ems and vancomycin.
 Inhibitors of Cell Membrane.
Polyenes - Amphotericin B, nystatin, and condi
cidin.
Amphotericin
Imidazole - Miconazole, ketoconazole and clotr
imazole.
Polymixin E and B.
 Inhibitors of Protein Synthesis.
Aminoglycosides Aminoglycosides - Streptomycin, gentamicin, n
eomycin and kanamycin.
Tetracyclines - Chlortetracycline, oxytetracyclin
e, doxycycline and minocycline.
Tetracyclines Erythromycin, lincomycin, chloramphenicol an
d clindamycin.
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 Modes of action (2)
 Inhibitors of metabolites (Antimet
abolites).
Sulfonamides - Sulfanilamide, sulfadiazine silver a
nd sulfamethoxazole.
Trimethoprim, ethambutol, isoniazid.

 Inhibitors of nucleic acids (DNA/R

NA polymerase).
Quinolones - Nalidixic acid, norfloxacin and ciprof
rifamycin loxacin.
Rifamycin and flucytosine. 

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 Penicillin: an extensively
studied example

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 Action mechanism of penicillin
 Action target: cell wall
 on penicillin binding proteins (PBPs)
 Transpeptidases (form cross-links in
peptidoglycan)
 Beta-lactam ring attached to 5-membered
thiazolidine ring
 Accessibility of PBPs differ in gram+ and gram-
bacteria
 Amino acyl side chain groups determine
spectrum, adsorption, susceptibility to
lactamase
 Bactericidal inhibitors

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 Pharmacokinetics of penicillins
 Adsorption: can be oral
Stability in acid condition:
 PenG (no)  Amoxacillin (yes)
 Pen V (yes)  Nafcillin (yes)
 Ampicillin (yes)  Peperacillin (no)

 Distribution: to most body sites; not in

CSF unless inframmed meninges
 Excretion: rapid eliminated by renal
secretion

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 Clinical status of Penicillins
 Pen G (Pen V): natural
 Common strptococci (S. pneumoniae; S. pyrogenes); URTI,
pneumonia meningitis, prophylaxis of rheumatic fever
 Nafcillin: penicillinase-resistant
 Staphylococci epidemic; bacteremia, septiemia
 Ampicillin:
 Gram- spectrum: E. coli; H. influenzae;Salmonella, shigella
pharngitis, otitis media, UTI, gastroenteritis
 Peperacillin:
 Expanded spectrum/antipsuedomonal, enteric bacilli;
Systemic infection in hospitalized patients (gram-, P
aeruginoma)
Combinations with b-lactamase
inhibitors:
URTI, pneumonias, meningitis, bactermia
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 Resistance
 Failure to bind to PBPs
 Cannot penetrate porins (gram-)
 Production of lactamase (penicillinase)
 Lack autolytic enzyme
 B-lactamase
Types:
 Different substrate specificity
 Penicillinases
Metallo-b-Lactamase
 cephalosporinases
Location:
 Gram+: extracellularly
 Gram-: periplasmic space
Serine-b-Lactamase
By Dr. Osnat Herzberg
University of Maryland Biotechnology Institute (UMBI)

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 Adverse effects

 Thrombophlebitis
 Allergic reactions
 Superinfections
(diarrhea)
 Seizures (rare)

Wickens K, Pearce N, Crane J, Beasley R.

Antibiotic use in early childhood and the
development of asthma. Clin Exp Allergy
1999;29:766-771.

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 Before on antibiotics:

–Antibiotics act as powerful sele

ctive factors in the emergence a
nd spread of resistant microora
ganism.

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 In Rwanda

聯合報 八十五年 四月十三日 頭版新聞

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  1953: Shigella outbreak in Japan, multiple drug
resistance
 1950: M tuberculosis largely resistant to streptomycin

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 Resistances
 Natural (inherent) resistance
 Structural barrel
 Lack of target
 Transport system

 Acquired resistance
 Mutation
 Gene exchange (conjugation in most)

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 Transferable antibiotic resistanc
e in bacteria
 Reduced uptake into cell (chloramphenicol)
 Active efflux from cell (tetracycline)
 Modification of antibiotic targets (b-lactam, erythro
mycin)
 inactivation of antibiotic by anzymic modificatio
n: hydrolysis (b-lactam, erythromycin); derivatization
(aminoglycosides)
 Sequestration of antibiotic by protein binding (b-la
ctam)
 Metabolic bypass (sulfonamides)
 Overproduction of antibiotic target (titration: sulfo
namides)

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 Spread of resistance
In most:

 Day-care, nursing homes,

correctional facilities
 Sanitation, animal feeds (fecal-oral)
 Sexual/ Respiratory transmission
 International travel
 Immunosuppression

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 Some probable overuse/misuse
of antibiotics
 Prophylatic use before surgery
 Empiric use (blinded use)
 Increased use of broad spectrum agents
 Pediatric use for viral infections
 Patients who do not complete course
(chronic disease, eg. TB, AIDS)
 Antibiotics in animal feeds

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 Policy to deal drug resistance (1)
 Ideally, bacteriological management of clinical
infection should involve:
1. Identification of causative organism
2. Sensitivity test
3. Follow-up the drug effect
4. Monitor antibiotic level to avoid toxicity.

 In reality, most patients requiring antimicrobial

therapy are treated empirically. In serious infections
immediate chemotherapy may be life-saving.

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 Policy to deal drug resistance (2)
 Periodic changes of antibiotics used might
change selective pressure and thus avoid the
emergence of resistance and retain the
therapeutic value of antibiotics over a longer
period.
 The unnecessary prophylactic or animal feeds
use should be discouraged.
 Distribution of information on
current/updated infectious microbes (consult
microbiologists): use more targeted
antibiotics
 Patient education ( 不隨便吃藥 , 停藥 )

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 New antibiotics development

 Pharmaceutical industry putting resources

back into discovery
 Liaisons with university researches
 Discoveries in microbial physiology and
genetics offering new targets, new
disciplines
 Combinational chemistry (mass screening)

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