Antimicrobial Agents and Chemotherapy

Medical Microbiology Module Lecture-3 College of Medicine University of Hail

Key Concepts
What are antimicrobial agents? Essential properties of an antimicrobial agent? How do they work? How resistance to antibiotics develop? How antibiotic susceptibility / resistance of a pathogen is determined ?

Terms
chemotherapeutic agent any drug used for any medical condition antimicrobial agent a chemical that destroys pathogens, includes antibiotics and chemically synthesized drugs antibiotic an antimicrobial agent produced naturally by a microorganism bactericidal capable of killing a microorganism bacteriostatic inhibits the growth of microorganisms

Point to note: All antibiotics are antimicrobial agents but all antimicrobial agents are not antibiotics

Bacteriostatic vs. Bactericidal

bacteriostatic - stop growth (don't kill) bactericidal kill cells Number of bacteria

No antibiotic
Bacteriostatic

Drug added

Bacteriocidal

Timeme

Essential Properties of an Antimicrobial Agent

Selective toxicity: Most important property Should be toxic to microorganism and should have no or minimum toxicity towards human cells. Critical thinking: What should be the target of an antimicrobial agents so that it can exhibit selective toxicity? Hint: Refer to differences between prokaryotic and eukaryotic cells

Essential Properties of an Antimicrobial Agent

Selective toxicity (high) Spectrum of activity (broad) Distribution, metabolism, excretion (acceptable) Interaction between drugs (Synergism) Resistance (No or minimum)

Selective Toxicity: Therapeutic Index

Measurement of the toxicity of a drug is called the therapeutic index the therapeutic index of a drug is a comparison of the amount that causes the therapeutic effect to the amount that causes toxic effects a high therapeutic index is LESS toxic.

Distribution, Metabolism, Excretion

antimicrobials have to get where they are needed a drug that is destroyed by acid cannot be taken orally the rate of elimination is expressed as the half-life of the drug the half-life is the time it takes the body to eliminate 1/2 of original dose knowing the half-life of a drug will determine how frequently the doses have to be administered this is why some medications are prescribed every four hours, others 2X per day

Spectrum of Activity
refers to the range of microorganisms that a antimicrobial agent can kill or inhibit broad spectrum affect a wide range of pathogens identification of the pathogen is not necessary narrow spectrum limited range of pathogens are affected requires the identification of the pathogen Critical thinking point: Why identification of a pathogen is needed when narrow spectrum of antibiotic is used ?

Interaction Between Drugs

combined drug therapy sometimes it is necessary to use two antimicrobial agents for successful treatment of an infection it is possible that one antimicrobial agent could influence the action of the other synergism action of one antimicrobial agent enhancing the others activity antagonistic action action of one interferes with the other additive neither synergistic or antagonistic

Critical thinking: What is the difference between MIC and MBC How to determine MIC / MBC of an antimicrobial agent?

Mechanisms of Action of Antimicrobials

different cell structures or microbial processes are the targets of antimicrobial agents structures that are different or absent from eukaryotic cells cell wall synthesis protein synthesis nucleic acid synthesis metabolic pathways plasma membrane integrity

Cell Wall Inhibitors

target peptidoglycan peptidoglycan only occurs in bacteria, which makes it an excellent target penicillin, cephalosporin, vancomycin, bacitracin (topical)

Protein Synthesis Inhibitors

all living organisms depend on protein synthesis inhibitors act at different stages of protein synthesis there is enough difference in the ribosomal structure (where proteins are synthesized) between prokaryotic and eukaryotic cells) aminoglycosides streptomycin, gentamicin, neomycin

Protein Synthesis Inhibitors

chloramphenicol last resort because of its rare, but lifethreatening side effects the inability to form red or white blood cells

DNA Replication Inhibitors

target is the enzymes necessary for DNA replication block bacterial DNA replication fluoroquinolones one of the enzymes inhibited is gyrase, which prevents the unwinding of the DNA double helix ciprofloxacin rifamycins blocks the initiation of transcription rifampin

Metabolic Pathway Inhibitors

very few of these agents are available sulfonamides (sulfa drugs) Trimethoprim the above 2 drugs inhibit the metabolism of folic acid at different steps in the process animal cells lack these enzymes makes folic acid a dietary requirement

Membrane Transport Inhibitors

damage to the plasma membrane leads to leakage of the cell contents and ultimately death of the cell polymyxins cause changes in structure of membrane can bind to eukaryotic cells limits the use of polymyxins to topical use

Resistance
4 major mechanisms that lead to antimicrobial agents resistance inactivation of the antimicrobial agent by an enzyme prevention of the antimicrobial agent from reaching its target cell structure alteration of the target cell structure so that it is no longer affected by the antimicrobial agent Efflux pumps actively pumps antiobiotics out of the cells

-Lactams
Antibiotics containing beta-lactam ring. Resistant bacteria produce enzyme beta-lactamase which cleaves the beta-lactam ring and destroy the drug. The Resistant gene can be located in chromosome or plasmid.
-lactam ring

Transfer of plasmid borne resistance gene through conjugation

Resistance to Antimicrobial Drugs

Reason: overuse and misuse of antimicrobial drugs resistance is generally a result of Breakdown of drugs by micromicrobial enzymes Inactivation (chemical modification) by drugs by microbial enzyme prevention of reaching target by inhibiting uptake prevention of reaching target by increasing export of drug from microbial cells Modification of target site

Mechanisms of Resistance-1
Point to note some resistance is innate, some is acquired. Pseudomonas aeruginosa is naturally resistant to many antimicrobial drugs as the organism is impermeable to many drugs. Resistance -inactivating enzymes (produced by the organism) the organism chemically modifies an antimicrobial drug to render it ineffective

Mechanisms of Resistance
2, alteration in target molecule structural changes from mutation of the organism prevents the drug from recognizing and binding to the target 3. decreased uptake of drug alterations in porin proteins found in the plasma membrane can alter permeability of the membrane may prevent some drugs from crossing the barrier and entering the cell

Mechanisms of Resistance
4. increased elimination efflux pumps are the mechanisms that bacterial cells use to eliminate harmful compounds from the cell an alteration that increases the expression of the efflux pumps , can increase the ability of a cell to eliminate an antimicrobial drug

Antimicrobial Susceptibility Testing

Kirby-Bauer qualitative determination of effectiveness automated liquid diffusion commercial modification that speeds up the process of determining the effectiveness of a drug able to know in 4 hours

Kirby-Bauer

Antibiotic Sensitivity Test

Kirby-Bauer Test (disc diffusion test)

Antibiotic Sensitivity Test

Etest (strip test): The strip contains different concentrations of antibiotics along its length

Antimicrobial Susceptibility Testing

determines effectiveness of an antimicrobial agent to a specific microorganism Minimum Inhibitory Concentration (MIC) determines the lowest concentration of an antimicrobial agent needed to prevent growth of the microorganism in the lab

Tests for finding Minimum inhibitory concentration

Antibiotic Sensitivity Test Broth Dilution Method

antibiotic (dilution series) + bacterial suspension (standard amount) growth ?

MIC minimal inhibitory concentration

Terms
Synergism Effectiveness of two or more drugs better than that of either drug alone. Antagonism The action one drug reduces the effectiveness of the other Indifference Each drug works no better or no worse alone or in combination

Adverse Effects
most all antimicrobial agents have concerns and dangers allergic reactions toxic effects to the body such as kidney damage suppression of normal flora normal flora is an important key to our immune system if it is altered too greatly, it can create an imbalance of those friendly microorganisms

Emerging Antimicrobial Resistance

Some examples of increasing resistance include: -- methicillin resistant S. aureus (MRSA) vancomyvin- resistant enterococci (VRE) and Vancomycin resistant S. aureus (VRSA) vancomycin is a last resort drug for enterococcal and staphylococcal infections the resistance to vancomycin is coded in the plasmid, so the potential for spreading to other organisms is possible.