Protein synthesis inhibitors

Protein synthesis inhibitors Aminoglycoside Antibiotics

The aminoglycoside group includes;

Gentamicin, Tobramycin, Amikacin, Kanamycin,

Streptomycin, and Neomycin.

At physiologic PH they are highly polar poly cation.

Can not readily cross membrane as a result.

Amino glycosides do not absorbed from GIT. Amino glycosides do not enter CSF. Rapidly excreted by the kidney
2

Aminoglycosides have a hexose ring, either streptidine (in

streptomycin) or 2-deoxystreptamine (other aminoglycosides), to which various amino sugars are attached by glycosidic linkages.

They are water-soluble, stable in solution, and more active at alkaline than at acid pH.

Mechanism of Action

1.

may involve two possibly synergistic effects

Inhibition of proteins synthesis

Aminoglycosides diffuse through porin of gram-negative bacteria and enter the periplasmic space.

Transport across the cytoplasmic membrane depends on

electron transport in part because of a requirement for a membrane electrical potential (interior negative) to drive permeation of these antibiotics.
4

This oxygen dependent transport has been termed energy-

dependent phase I (EDP1).

EDP1 transport is affected by several factors:

Divalent cations (Ca2+ and Mg2+), Hyperosmolarity, A reduction in pH, and Anaerobic conditions

Once inside the cell they bind to their targets in the 30S and
or 50S ribosomal subunit and interfere with protein synthesis by:

Inhibiting the binding of initiator t-RNA to the 30S.

Inducing errors in the translation of messenger RNA to peptides.

Causing miss reading of the genetic code.

Premature termination of translation with detachment of the ribosomal complex and incompletely synthesized

protein.
6

The resulting defective proteins may be inserted into the cell membrane, leading to altered permeability and further

stimulation of aminoglycoside transport.

Termed energy-dependent phase II (EDP2) transport.

The disruption of membrane leads to leakage of intercellular molecules cell death.

 A.

AG (represented by closed circles):-

Binds to the 30S ribosomal subunit and interferes with initiation of protein
synthesis by fixing the 30S-50S ribosomal complex at the start codon (AUG) of mRNA.

B.

Premature termination of translation with detachment of the ribosomal complex and incompletely synthesized protein,

C.

Incorporation of incorrect amino acids (indicated by the X), resulting in the production of abnormal or nonfunctional proteins
8

2.

Direct disruption of membrane integrity.

The +vely charged aminoglycoside binds to vely charged sites on the outer bacterial membrane, thereby disrupting membrane integrity.

It is likely that the aminoglycoside-induced bacterial outer membrane degradation.

Resulting in leakage of intracellular contents and enhanced antibiotic uptake.

This rapid action at the outer membrane probably accounts for most of the bactericidal activity.

Mechanism of Resistance

1.

Three major mechanisms

Reduced permeability into bacterial cells this could be;

Deletion of the porin, deletion of transport proteins or mutation leading to altered membrane gradient.

Strictly anaerobic bacteria are resistant because they lack (EDP1).

10

2.

Elaboration of aminoglycoside modifying enzymes.

Plasmid-mediated expression of enzymes that acetylate,

adenylate, or phosphorylate the aminoglycosides.

This is the most clinically important mechanism

3.

Ribosomal alteration

The receptor proteins on the 30S ribosomal subunit may be altered as a result of mutation.

Occurs for streptomycin but not common to others.

11

Antibacterial Spectrum

Have little or no activity against anaerobic microorganisms. Their action against most gram-positive bacteria is limited,

They should not be used as single agents to treat infections caused by gram-positive bacteria.

Have a variable activity against aerobic gram-negative

organisms.

12

Adverse Effects
1.

Ototoxicity

Can cause both vestibular and auditory ototoxicity, both of which can be irreversible.

Loop diuretics aggravate ototoxicity of aminoglycoside.

13

2.

Nephrotoxicity AG can diffuse from the tubular lumen subsequent endocytosis and accumulation in lysosomes;

Within the lysosomes, it will bind to anionic phospholipids, inhibiting lysosomal phospholipase A2 lysosomal distension, rupture, and release of acid hydrolases and the aminoglycoside into the cytosol

Free aminoglycoside then binds to other cellular organelles degeneration and cell necrosis.

The severity of aminoglycoside nephrotoxicity is additive with that of vancomycin, polymixin, furosemide, enflurane, cisplatin etc
14

3.

Neuromuscular blockade

High dose produce curare like effects such as apnea and respiratory paralysis.

It is due to inhibition of NT release or reduction of sensitivity of post synaptic receptors.

Can be treated with Ca++ or cholinesterase inhibitors (eg.

Neostigmin)

4.

Hypersensitivity reaction

May occur rarely

15

Therapeutic Uses

Endocarditis

A combination of gentamicin and ampicillin is recommended as prophylaxis of endocarditis prior to surgery.

The use of penicillin that alters the cell wall structure can markedly increase the enterance of aminoglycosides into the bacteria and this is an excellent example of synergism between antibiotics.
16

Meningitis

In combined with the -lactams or other antibiotics

Tuberculosis

Streptomycin is used.

Other infection

Ophthalmological Infection Gonococcal Urethritis Serious Gram-Negative Bacillary Infections

17

 Tetracyclines

Individual tetracycline differ significantly in their pk All of the tetracycllines are orally active
18

Classification

Short acting tetracycline

Tetracycline, Oxyteracyclline

Intermediate acting

Demeclocyclline , Methacyclline

Long acting

Doxycyclline, Minocyclline

19

Mechanism of Action

Their primary mode of action is inhibition of protein synthesis. TTCs enter gram ve bacteria by passive diffusion through the porin proteins and by energy-dependent active transport that pumps all tetracyclines across the cytoplasmic membrane.

Mammalian cells lack this transport ( Do not actually accumulate the drug )

20

Once inside the cell they bind to 30S ribosomal subunit and thereby prevent the binding of aminoacyl transfer RNA (tRNA) to the A site (acceptor site) on the 50S ribosomal unit.

21

Therapeutic Uses

The TTCs are the drug of choice in infections with Mycoplasma pneumoniae, Chlamydiae, Rickettsiae, and some Spirochetes.

They are used in combination regimens to treat gastric and

duodenal ulcer disease caused by Helicobacter pylori.

22

Tetracyclines remain effective in most Chlamydia infections,

including, treatment of cholera and sexually transmitted diseases but no longer recommended for treatment of gonococcal disease because of resistance.

Tetracyclines are sometimes employed in the treatment of protozoal infections,

Entamoeba histolytica or Plasmodium falciparum

23

Demeclocycline inhibits the action of ADH in the renal tubule and has been used in the treatment of inappropriate secretion of ADH or similar peptides by certain tumors.

Doxycycline is a potential first-line agent in the prophylaxis of anthrax after exposure.

24

Adverse Effects

Gastrointestinal

Epigastric burning and distress, abdominal discomfort, nausea, vomiting, and diarrhea may occur.

TTCs affect normal flora, for example Pseudomembranous colitis caused by overgrowth of Clostridium difficile is a potentially life-threatening complication

Treated with metronidazole.

25

Bone and Teeth

Readily bound to calcium deposited in newly formed bone or teeth in young children.

Given during pregnancy, it can be deposited in the fetal teeth, leading to fluorescence, discoloration, and enamel dysplasia; it can also be deposited in bone, where it may cause deformity or growth inhibition.

If the drug is given for long periods to children under 8 years of age, similar changes can result.
26

Kidney Toxicity

Tetracyclines other than doxycycline may accumulate to toxic levels in patients with impaired kidney function.

Local Tissue Toxicity

Intravenous injection can lead to venous thrombosis. Intramuscular injection produces painful local irritation and should be avoided.

Photosensitization

Observed as abnormal sunburn reaction, Is particularly associated with demeclocycline and doxycycline administration.
27

Vestibular Reactions

Dizziness, vertigo, nausea, and vomiting have been particularly noted with doxycycline at doses above 100 mg.

With dosages of 200400 mg/d of minocycline,

3570% of patients will have these reactions.

Hypersensitivity reactions

Hypersensitivity reactions (drug fever, skin rashes) to tetracyclines are uncommon.

28

Chloramphenicol

Chloramphenicol, an antibiotic produced by Streptomyces

venezuelae.

29

Mechanism of Action

Chloramphenicol inhibits protein synthesis in bacteria, and to a lesser extent, in eukaryotic cells.

The drug readily penetrates bacterial cells and acts primarily

by binding reversibly to the 50S ribosomal subunit.

Prevents the binding of the amino acid-containing end of

the aminoacyl tRNA to the acceptor site on the 50S

ribosomal subunit.

30

The interaction b/n peptidyltransferase and its amino acid substrate cannot occur, and peptide bond formation is inhibited

31

Chloramphenicol also can inhibit mitochondrial protein

synthesis in mammalian cells, perhaps because mitochondrial ribosomes resemble bacterial ribosomes (both are 70S) more than they do the 80S cytoplasmic ribosomes of mammalian cells .

Mammalian erythropoietic cells are particularly sensitive to the drug.

32

Mechanism of Resistance

Due to production of a plasmid-encoded acetyltransferase that inactivates the drug.

Resistance also can result from decreased permeability and from ribosomal mutation.

33

Spectrum of Activity

Chloramphenicol is a broad-spectrum antibiotic that is effective against gram-positive and gram-negative bacteria, including Rickettsia, Mycoplasma, and Chlamydia spp.

It is also effective against most anaerobic bacteria, including Bacteroides fragilis.

It is bacteriostatic against most species, It may be bactericidal against H. influenzae, Neisseria meningitis, and S. pneumoniae

34

Adverse Effects
1.

Hematological Toxicity

The most important adverse effect which limits its use.

Manifestations include anemia, leukopenia, or

thrombocytopenia; and an idiosyncratic aplastic anemia.

CAF inhibits the synthesis of proteins of the inner

mitochondrial membrane, probably by inhibiting the

ribosomal peptidyltransferase.

35

The bone marrow depression is dose related and is reversible on discontinuation of CAF.

The risk of aplastic anemia does not contraindicate the use

of chloramphenicol in situations in which it may be lifesaving but the drug should never be used if alternative

treatment is available.

36

2.

The gray baby syndrome

Newborn infants, especially those born prematurely, cannot adequately conjugate chloramphenicol to form the glucuronide; they also have depressed rates of glomerular and tubular secretion.

Vomiting, flaccidity, hypothermia, gray color, shock,

and collapse.

37

Other adverse effects

Nausea and vomiting, unpleasant taste, diarrhea, and perineal irritation after oral administration.

Tissues that have a high rate of oxygen consumption may be particularly susceptible to chloramphenicol effects on mitochondrial enzyme systems encephalopathy and cardiomyopathy have been reported.

Rarely hypersensitivity reactions.

38

Clinical Uses

Chloramphenicol is no longer recognized as the treatment of choice for any bacterial infection other effective antimicrobial agents are available in almost all instances.

It is now reserved for treatment of life-threatening infections in patients who cannot take safer alternatives because of resistance or allergies.

There is no justification for its use in treating minor infections.

39

Potential uses include

1. 2.

Typhoid fever Bacterial Meningitis

3.
4.

Anaerobic Infections
Other uses

It is used as an alternative to TTCs in Rickettsial Diseases and Brucellosis.

40

Drug interaction

Inhibits cytochrome P450 isozymes warfarin, dicumarol, phenytoin, chlorpropamide, antiretroviral protease inhibitors, rifabutin, and tolbutamide.

Phenobarbital or rifampin shorten its the half-life.

41

Macrolides

42

The prototype drug is Erythromycin, obtained from Streptomyces erythreus.

Clarithromycin and Azithromycin are semisynthetic derivatives of erythromycin.

Oleandomycin is not commonly used, its acetylated derivative, Troleandomycin, is available for oral use.

43

Mechanism of Action

Macrolides bind to the 50S ribosomal subunit of bacteria at or very near the site that binds chloramphenicol.

inhibit the translocation step where in a newly synthesized peptidyl tRNA molecule moves from the acceptor site on the ribosome to the peptidyl donor site.

Protein synthesis is inhibited.

44

But not to the 80S mammalian ribosome; this accounts for its selective toxicity

45

Mechanisms of resistance

Four mechanisms have been identified.

1. 2.

Drug efflux by an active pump mechanism. Ribosomal protection by inducible or constitutive production of methylase enzymes which modify the ribosomal target and decrease drug binding.

3.

Macrolide hydrolysis by esterases produced by Enterobacteriaceae.

4.

Chromosomal mutations that alter a 50S ribosomal protein.

46

Antibacterial Spectrum

The macrolides are effective against a number of organisms, including Mycoplasma spp., H. influenzae, Streptococcus spp. (including S. pyogenes and S. pneumoniae), staphylococci, gonococci, Legionella pneumophila, and other Legionella spp.

Clarithromycin is very active against H. influenzae, Legionella, and Mycobacterium avium-intracellulare, whereas

Azithromycin is superior against Neisseria, and H. influenzae but less active against mycobacterial species.

47

Clinical Uses
1.

Mycoplasma pneumoniae Infections

A macrolide or tetracycline is the drug of choice for

mycoplasma infections.
2.

Legionnaires' Disease

Acute (sometimes fatal) lobar pneumonia.

Characterized by fever, muscle and chest pain, headache,

chills and a dry cough.

Erythromycin has been considered as the drug of choice

for treatment of pneumonia caused by L. pneumophila, L.

micdadei, or other Legionella spp
48

3.

Chlamydial Infections.

Chlamydial infections can be treated effectively with any of the macrolides.

During pregnancy, erythromycin base is recommended as first-line therapy for chlamydial urogenital infections.

4.

Diphtheria

Erythromycin is very effective for acute infections or for eradicating the carrier state.

49

5.

Whooping cough (Pertussis)

Erythromycin is the drug of choice. Clarithromycin and Azithromycin also are effective.

6.

Helicobacter pylori Infection

Clarithromycin 500 mg, in combination with omeprazole, 20 mg, and amoxicillin, 1 g, each administered twice daily for 10 to 14 days, is effective for treatment of peptic ulcer disease caused by H. pylori

50

7.

Mycobacterial Infections.

Clarithromycin or Azithromycin is recommended as firstline therapy for prophylaxis and treatment of

disseminated infection caused by M. avium-intracellulare

in AIDS patients and for treatment of pulmonary disease in non-HIV-infected patients.

Clarithromycin also has been used with minocycline for

the treatment of Mycobacterium leprae in lepromatous leprosy

51

8.

Syphilis.

Erythromycin has been used in the treatment of early syphilis in patients who are allergic to penicillin, but it no

longer is recommended.

Tetracyclines are the recommended alternative in penicillin-allergic patients.

9.

Other uses

Streptococcal Infections, Staphylococcal Infections, Campylobacter Infections

In the treatment of toxoplasmosis encephalitis and

diarrhea due to Cryptosporidium in AIDS patients
52

Adverse Effects

Gastrointestinal Effects

Occasionally anorexia, nausea, vomiting, and diarrhea.

Gastrointestinal intolerance may occur because

Erythromycin stimulates gastrointestinal motility by acting on motilin receptors.

Has been used to promote peristalsis postoperatively

and to speed gastric emptying.

53

Liver Toxicity

Cholestatic hepatitis is the most striking side effect.

It is caused primarily by erythromycin estolate and rarely by the ethylsuccinate or the stearate.

54

Other adverse effects

Allergic reactions - fever, eosinophilia, and skin eruptions. Erythromycin has been reported to cause cardiac arrhythmias, including QT prolongation with ventricular tachycardia.

Erythromycin has also been associated with transient auditory impairment

55

Drug Interactions

Erythromycin and clarithromycin inhibit CYP3A4 and are associated with clinically significant drug interactions.

Erythromycin potentiates the effects of carbamazepine,

corticosteroids, cyclosporine, digoxin, ergot alkaloids, theophylline,, valproate, and Warfarin.

Azithromycin does not inactivate cytochrome P450 enzymes

and therefore is free of the drug interactions that occur with erythromycin and clarithromycin.

56

Summary (1) chloramphenicol; (2) macrolides, clindamycin, and

type B streptogramins; and (3) tetracyclines

57

58