Antimicrobial chemotherapy - history - principles and practice - mode of action, resistance. Dr. Berek Zsuzsa. 01 October 2013
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1 Antimicrobial chemotherapy - history - principles and practice - mode of action, resistance Dr. Berek Zsuzsa 01 October 2013
2 How to kill Microbes? Extracorporal sterilisation disinfecting prevention Intracorporal Antimicrobial drugs chemotherapy antibiotics treatment (prevention)
3 Historical overview experimental, mold-on-bread quinine, emetine Ehrlich Arsphenamines, aniline dyes (sleeping sickness, trypanosomes) th drug SALVARSAN Domagk 1930-s sulphonamides Fleming Penicillin et al. Waksman 1950-s streptomycin + aminoglycosides
4 The father of chemotherapy aerzteblatt.lnsdata.de,
5 rex.nci.nih.gov
6
7
8 Gerhard Domagk sulfonamides
9 clendening.kumc.edu Nobel prize 1939 (1947)
10 Penicillin Sir Alexander Fleming
11 Sir Howard Walter Florey Ernst Boris Chain Nobel prize 1945 Fleming Florey Chain
12 Selman Abraham Waksman Streptomycin Nobel prize 1952 and Fleming
13 Antimicrobial drugs Chemotherapy - drugs produced in laboratory Antibiotics - produced by other micro-organism Principle: selective toxicity (Ehrlich): Antimicrobial drug should be toxic to the (pathogen) microbe and possibly harmless to the host (human being)
14 Chemotherapeutical index: C i = dosis tolerata maxima dosis curativa minima The drug should be tolerated by the HOST as high dose as possible, and cure the HOST as low dose as possible.
15 Kaiser s Abb Principles of antimicrobial treatment DRUG HOST
16 Principles of antimicrobial treatment correct indication when to give? - in order to: TREAT or AVOID an infection what to give? the most suitable 1. the most effective one 2. the less toxic one 3. (the cheapest)
17 Principles of antimicrobial treatment Ad 1. effective A/ antimicrobial activity - spectrum = against which species is it effective? - numerically expressed: MIC, MBC (minimal inhibitory/bactericidal concentration) the sensitivity of a bacterium can be detected in vitro
18 Principles of antimicrobial treatment B/ pharmacokinetic features selective toxicity (Ad 2.) Side effects: C/ resistance - kidney - liver - bone marrow (- nerves, GI)
19 Principles of antimicrobial treatment how much to give the satisfactory dose is the multiple amount of MIC at the locus of infection! Dosage: how long to give? - age - liver and kidney functions - body weight and hight - pregnancy as long as there is no danger of relapse acute infection: min. 5 days severe infection: 8-14 days sepsis/endocarditis: weeks, tbc: 9-12 months
20 Magic bullets... Antibiotic tablets - per os application sensitive HALT!
21 Effect of antimicrobial drugs on bacterium cell membrane cell wall DNA proteinsynthesis
22 Antimicrobial drugs I. Cell wall synthesis inhibition Beta lactam drugs 1. penicillines amino-, carboxi-, ureido and anti-staphylococcal penicillines 2. cephalosporines generations: I., II., II., IV. 3. others (monobactam, carbapenem)
23 Antimicrobial drugs II. Cell membrane destruction Polymyxin-B and - M III. Nucleic acid level Quinolons, fluoroquinolons (gyrase inhibitors) metronidazole = Klion (DNA damage by toxic metabolites)
24 Antimicrobial drugs IV. Protein synthesis inhibition - 30s ribosome subunit Tetracyclines Aminoglycosides - 50s ribosome subunit chloramphenicol Macrolides and lincosamides Erythromycin group and Clindamycin Oxazolidinones/linezolide (Zyvox ) Ketolides Quinupristin-dalfopristin
25 Antimicrobial drugs V. Folic acid synthesis inhibition Sulphonamides, trimethoprim VI. Complex mode of action Glycopeptides (Vancomycin, Teicoplanin) 1. Cell wall 2. Permeability (cell wall - membrane) 3. DNA synthesis
26 Antimicrobial drugs I. Cell wall synthesis inhibition Beta lactam drugs 1. penicillines 2. cephalosporines 3. others (monobactam, carbapenem) II. Cell membrane destruction Polymyxin-B and - M III. Nucleic acid level 1. Quinolons, fluoroquinolons (gyrase inhibitors) 2. metronidazole = Klion (DNA damage by toxic metabolites)
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29 io141/lecguide/unit2/control/penres_ fl.html
30 Antimicrobial drugs I. Cell wall synthesis inhibition Beta lactam drugs 1. penicillines 2. cephalosporines 3. others (monobactam, carbapenem) II. Cell membrane destruction Polymyxin-B and - M III. Nucleic acid level 1. Quinolons, fluoroquinolons (gyrase inhibitors) 2. metronidazole = Klion (DNA damage by toxic metabolites)
31
32 Antimicrobial drugs I. Cell wall synthesis inhibition Beta lactam drugs 1. penicillines 2. cephalosporines 3. others (monobactam, carbapenem) II. Cell membrane destruction Polymyxin-B and - M III. Nucleic acid level 1. Quinolons, fluoroquinolons (gyrase inhibitors) 2. metronidazole = Klion (DNA damage by toxic metabolites)
33 Fluoroquinolones mode of action
34 Antimicrobial drugs I. Cell wall synthesis inhibition Beta lactam drugs 1. penicillines 2. cephalosporines 3. others (monobactam, carbapenem) II. Cell membrane destruction Polymyxin-B and - M III. Nucleic acid level 1. Quinolons, fluoroquinolons (gyrase inhibitors) 2. metronidazole = Klion (DNA damage by toxic metabolites)
35
36 Metronidazole mode of action TOXIC Medmicro ch. 11
37 Antimicrobial drugs IV. Protein synthesis inhibition - 30s ribosome subunit Tetracyclines Aminoglycosides - 50s ribosome subunit chloramphenicol Macrolides and lincosamides Erythromycin group and Clindamycin Oxazolidinones/linezolide (Zyvox ) Ketolides Quinupristin-dalfopristin
38 Protein synthesis
39 Antimicrobial drugs IV. Protein synthesis inhibition - 30s ribosome subunit Tetracyclines Aminoglycosides - 50s ribosome subunit chloramphenicol Macrolides and lincosamides Erythromycin group and Clindamycin Oxazolidinones/linezolide (Zyvox ) Ketolides Quinupristin-dalfopristin
40 Initiation of protein synthesis and antibiotics that inhibit initiation
41 Antimicrobial drugs IV. Protein synthesis inhibition - 30s ribosome subunit Tetracyclines Aminoglycosides - 50s ribosome subunit chloramphenicol Macrolides and lincosamides Erythromycin group and Clindamycin Streptogramins Oxazolidinones/linezolide (Zyvox ) Ketolides, Quinupristin-dalfopristin
42 Elongation of proteins and antibiotics that inhibit elongation
43 Antimicrobial drugs IV. Protein synthesis inhibition - 30s ribosome subunit Tetracyclines Aminoglycosides - 50s ribosome subunit chloramphenicol Macrolides and lincosamides Erythromycin group and Clindamycin Streptogramins Oxazolidinones/linezolide (Zyvox )
44 August 2005 Molecule of the Month Linezolid
45 Mode of action
46 Antimicrobial drugs IV. Protein synthesis inhibition - 30s ribosome subunit Tetracyclines Aminoglycosides - 50s ribosome subunit chloramphenicol Macrolides and lincosamides Erythromycin group and Clindamycin Streptogramins Oxazolidinones/linezolide (Zyvox ) Ketolides, Quinupristin-dalfopristin
47 Comparison of antibiotic binding sites. (A) (B) Overview of the binding sites of quinupristin and dalfopristin within the 50S ribosomal subunit, in relation to the P-site trna and the ribosomal exit tunnel (highlighted in gold).
48 Antimicrobial drugs V. Folic acid synthesis inhibition Sulphonamides, trimethoprim VI. Complex mode of action Glycopeptides (Vancomycin, Teicoplanin) 1. Cell wall 2. Permeability (cell wall - membrane) 3. DNA synthesis
49 Synthesis of tetrahydrofolic acid and antibiotics that inhibit its synthesis
50 Antimicrobial drugs V. Folic acid synthesis inhibition Sulphonamides, trimethoprim VI. Complex mode of action Glycopeptides (Vancomycin, Teicoplanin) 1.Cell wall 2.Permeability (cell wall - membrane) 3.DNA synthesis
51 Vancomycin 3D structure
52 "antibiotic of last-resort," chemical formula, C 66 H 75 Cl 2 N 9 O 2, shows that it is a large molecule chlorine-containing antibiotic produced by the soil bacteria, Streptomyces orientalis www-personal.umich.edu/
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55 tudent.ccbcmd.edu/courses/bio141/lecguide/u nit2/control/images/vanresanim.gif&imgrefurl= uide/unit2/control/vanres.html&h=278&w=345 &sz=1168&hl=hu&start=108&tbnid=4mnyyhrq pmwttm:&tbnh=97&tbnw=120&prev=/images% 3Fq%3Dvancomycin%26start%3D100%26gbv %3D2%26ndsp%3D20%26svnum%3D10%26 hl%3dhu%26sa%3dn 1/lecguide/unit2/control/vanres.html student.ccbcmd.edu/.../images/vanresanim.gif
56 student.ccbcmd.edu
57 Antibiotic combinations Antagonism A + B = kill each other Synergism A + B = D, where D C Additive A + B = C, where C = A + B Neutral A + B = A and B AIMS 1. Broaden the spectrum 2. Prevent and/or delay the resistance to develop 3. synergism
58 Side effects allergy - penicillin dysbacteriosis candidiasis Normal flora damage - broad spectrum drugs direct toxic damage - aminoglycosides (kidney) - chloramphenicole (bone marrow) - tetracyclines (teeth) - Vancomycin (kidney, ears )
59 Resistance GENETIC BACKGROUND OF RESISTANCE: - mutation (chromosome) - plasmid coded R genes usually both Tools Enzymes produced Binding receptor modification Permeability Efflux pump (active)
60 Resistance to 1. Beta lactam drugs 2. Macrolides and lincosamides 3. Chloramphenicole = Chlorocid 4. Tetracyclines 5. Aminoglycosides 6. Fluoroquinolones 7. Sulfonamides 8. Metronidazole
61 Resistance to 1.Beta lactam drugs - inhibit the peptidoglycan transpeptidation Both chromosomal and plasmid beta lactamase enzyme hydrolysis (beta lactam ring breaks ) trapping beta lactamase + cephalosporin = irreversible complex amidase and acylase enzymes altered structure of PBP (penicillin binding protein) permeability
62 beta lactamase enzyme hydrolysis (beta lactam ring breaks )
63
64
65 permeability enzyme!
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68 Beta lactam antibiotics Beta lactamase enzyme Beta - Lactamase Inhibitors Clavulanic acid Sulbactam Tazobactam In combination with beta lactam drugs
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70 TEM1 beta-lactamase structure
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72 2. Macrolides and lincosamides et.al -Alteration of rrna receptor by methylation (ketolide) -Efflux
73 Resistance to 3. Chloramphenicol = Chlorocid enzymatic inactivation 4. Tetracyclines Permeability -Ribosome-tRNA stabilisation no inhibition of protein synthesis 5. Aminoglycosides - plasmid adenylase, phosphorilase, acetylase enzymes inactivation and/or structural changes
74 6. Fluoroquinolones - DNA gyrase subunit A change /enzyme mutation/ no binding - Permeability - Efflux
75
76 Resistance to 7. Sulfonamides - higher affinity to PABA (enzyme) - more PABA produced (mutation) - inactivation by acetyltransferase (plasmid) 8. Metronidazole rarely seen
77 Antibiotic Year marketed Year Resistance first observed Sulfonamides Penicillin Streptomycin Chloramphenicol Tetracycline Erythromycin Methicillin Ampicillin Cephalosporins 1960s late 1960s Palumbi, S.R Humans as the World's Greatest Evolutionary Force. Science 293:
78 Anti-staphylococcal drugs
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82 Daptomycin Mode of action: Cell membrane depolarisation and subsequent inhibition of DNA, RNA and protein metabolism
83 Gram-positive skin infections can now be treated with Cubicin (daptomycin), which is the first of a new class of antibiotics to be approved by the FDA in over two decades. Cubist Pharmaceuticals
84 COSTS OF HUMAN-INDUCED EVOLUTION IN SOME INSECT PESTS AND DISEASES Disease/Pest Cost per year Additional pesticide application $1,200,000,000 Loss of crops $2-7,000,000,000 S. aureus Penicillin-resistant $ 2-7,000,000,000 S. aureus Methicillin-resistant $ 8,000,000,000 Community-acquired resistant $14-21,000,000,000 HIV drug resistance $ 6,300,000,000 Total for these factors $ 33-50,000,000,000 Stephen R. Palumbi Humans as the world's greatest evolutionary force. Science 293:
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86 Telendos, 2005 THE END Photo: istvan-istvan
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