Antimicrobial chemotherapy - history - principles and practice - mode of action, resistance Dr. Berek Zsuzsa 01 October 2013
How to kill Microbes? Extracorporal sterilisation disinfecting prevention Intracorporal Antimicrobial drugs chemotherapy antibiotics treatment (prevention)
Historical overview experimental, mold-on-bread quinine, emetine www.nobelprize.org Ehrlich 1906 1910 - Arsphenamines, aniline dyes (sleeping sickness, trypanosomes) - 606 th drug SALVARSAN Domagk 1930-s sulphonamides Fleming 1928 1940 Penicillin et al. Waksman 1950-s streptomycin + aminoglycosides
The father of chemotherapy 1854-1915 aerzteblatt.lnsdata.de, 1909 www.paul-ehrlich-symposium-2004.de www.nobelprize.org, www.germannotes.com, www.chemheritage.org www.dw-world.de
www.amuseum.de, www.md.ucl.ac.be, rex.nci.nih.gov
www.personal.psu.edu, www.jbirc.aist.go.jp
www.dhm.de, www.rpsgb.org.uk, www.personal.psu.edu www.britannica.com, www.nobelprize.org
Gerhard Domagk 1895-1964 www.uni-muenster.de www.nobelpreis.org, www.nobelprize.org sulfonamides
www.britannica.com, clendening.kumc.edu Nobel prize 1939 (1947)
Penicillin www.gesundheit.de www.nobelprize.org, www.workersforjesus.com Sir Alexander Fleming 1881-1955
www.asap.unimelb.edu.au Sir Howard Walter Florey 1898-1968 Ernst Boris Chain 1906-1979 www.nobelprize.org, www.britannica.com Nobel prize 1945 Fleming Florey Chain
Selman Abraham Waksman 1888-1973 Streptomycin Nobel prize 1952 and Fleming
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)
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.
Kaiser s Abb. 4.27 Principles of antimicrobial treatment DRUG HOST
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)
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
Principles of antimicrobial treatment B/ pharmacokinetic features selective toxicity (Ad 2.) Side effects: C/ resistance - kidney - liver - bone marrow (- nerves, GI)
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: 3-4-6 weeks, tbc: 9-12 months
Magic bullets... Antibiotic tablets - per os application sensitive HALT!
Effect of antimicrobial drugs on bacterium cell membrane cell wall DNA proteinsynthesis
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) www.med.sc.edu:85
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)
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
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
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) www.med.sc.edu:85
www.med.sc.edu:85
www.med.sc.edu:85
http://student.ccbcmd.edu/courses/b io141/lecguide/unit2/control/penres_ fl.html
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) www.med.sc.edu:85
www.med.sc.edu:85
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) www.med.sc.edu:85
Fluoroquinolones mode of action www.idinchildren.com
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) www.med.sc.edu:85
www.crsq.org
Metronidazole mode of action TOXIC Medmicro ch. 11
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
Protein synthesis www.scq.ubc.ca/.../2006/08/proteinsynthesis.gif
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
Initiation of protein synthesis and antibiotics that inhibit initiation www.med.sc.edu:85
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
Elongation of proteins and antibiotics that inhibit elongation www.med.sc.edu:85
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 )
August 2005 Molecule of the Month Linezolid www.chm.bris.ac.uk/motm/linezolid/30s.gif
www.chemsoc.org Mode of action
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
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). www.biomedcentral.com
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
Synthesis of tetrahydrofolic acid and antibiotics that inhibit its synthesis www.med.sc.edu:85
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
Vancomycin 3D structure www.ioc.uni-karlsruhe.de
www.americanchemistry.com "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/
www.vhcy.gov.tw www.appdrugs.com/prodjpgs/vancomycinlg.jpg
www.dundee.ac.uk
http://images.google.hu/imgres?imgurl=http://s tudent.ccbcmd.edu/courses/bio141/lecguide/u nit2/control/images/vanresanim.gif&imgrefurl= http://student.ccbcmd.edu/courses/bio141/lecg 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 http://student.ccbcmd.edu/courses/bio14 1/lecguide/unit2/control/vanres.html student.ccbcmd.edu/.../images/vanresanim.gif
student.ccbcmd.edu
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
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 )
Resistance GENETIC BACKGROUND OF RESISTANCE: - mutation (chromosome) - plasmid coded R genes usually both Tools Enzymes produced Binding receptor modification Permeability Efflux pump (active)
Resistance to 1. Beta lactam drugs 2. Macrolides and lincosamides 3. Chloramphenicole = Chlorocid 4. Tetracyclines 5. Aminoglycosides 6. Fluoroquinolones 7. Sulfonamides 8. Metronidazole
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
beta lactamase enzyme hydrolysis (beta lactam ring breaks ) www.isrvma.org
permeability enzyme! www.med.sc.edu:85
www.med.sc.edu:85
Beta lactam antibiotics Beta lactamase enzyme Beta - Lactamase Inhibitors Clavulanic acid Sulbactam Tazobactam In combination with beta lactam drugs
www.javeriana.edu.co www.isrvma.org
TEM1 beta-lactamase structure www.antibioresistance.be
www.mgm.ufl.edu/~gulig/bacgen/pg-inhib2.gif
2. Macrolides and lincosamides et.al -Alteration of rrna receptor by methylation (ketolide) -Efflux www.princetoncme.com
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
6. Fluoroquinolones - DNA gyrase subunit A change /enzyme mutation/ no binding - Permeability - Efflux www.facm.ucl.ac.be
www.idinchildren.com
Resistance to 7. Sulfonamides - higher affinity to PABA (enzyme) - more PABA produced (mutation) - inactivation by acetyltransferase (plasmid) 8. Metronidazole rarely seen
Antibiotic Year marketed Year Resistance first observed Sulfonamides 1930 1940 Penicillin 1943 1946 Streptomycin 1943 1959 Chloramphenicol 1947 1959 Tetracycline 1948 1959 Erythromycin 1952 1988 Methicillin 1960 1961 Ampicillin 1961 1973 Cephalosporins 1960s late 1960s Palumbi, S.R. 2001. Humans as the World's Greatest Evolutionary Force. Science 293: 1786-1790. www.geo.arizona.edu
www.geo.arizona.edu Anti-staphylococcal drugs
www.3db.co.uk/media/showcase/cubicin/cubicin2.jpg
www.3db.co.uk/media/showcase/cubicin/cubicin2.jpg
Daptomycin Mode of action: Cell membrane depolarisation and subsequent inhibition of DNA, RNA and protein metabolism www.chem.ubc.ca/.../faculty/scotty/dapto.jpg
www.nature.com/.../v21/n11/images/nbt904-i1.jpg 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
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. 2001. Humans as the world's greatest evolutionary force. Science 293: 1786-1790. www.geo.arizona.edu
www.geo.arizona.edu
Telendos, 2005 THE END Photo: istvan-istvan