Principles of Antimicrobial Therapy

Overview
• Antimicrobial drugs are effective for treating infections

• They have selective toxicity

• Conc. of drug is carefully controlled to attack microorganisms

• They are tolerated by the host.

Antibacterials
• Antibacterials are used to treat bacterial infections.

• It shows less or no toxicity to humans than bacteria.

• It kills bacteria or inhibits the growth of it.

• E.g. Penicillin, Cephalosporin, Azithromycin etc.

Antivirals
• a class of medication used specifically for treating viral infections.

• Like antibiotics, specific antivirals are used for specific viruses.

• They are relatively harmless to the host and therefore can be used
to treat infections. e.g. Acyclovir (herpes, AIDS) , Valacyclovir etc.
Antifungals
• Antifungals are used to kill or prevent further growth of fungi.

• They may me used topically or intravenously.

e.g. Ketoconazole, myconazole, griseofulvin etc.

Selection of Antimicrobial Agents
Selection requires knowledge of-
• the organism’s identity
• its susceptibility to a particular agent
• the site of the infection
• patient factors
• the safety of the agent
• the cost of the therapy
Bacterial cell
Bacterial cell wall contains peptidoglycan
• Peptidoglycan cell wall is composed of
disaccharides & AA.
• Cell wall gives structural strength
• Counteracts the osmotic pressure of the
cytoplasm.
• Cell wall is often a target for antibiotic
• Bacterial cell (Contd.)

• gram +ve bacteria have thick peptidoglycan layer.

• gram -ve bacteria have thin peptidoglycan layer.
• peptidoglycans are surrounded by lipid membrane
containing lipopolysacccharides & lipoproteins in
Gram -ve.
• In gram –ve bacteria, this membrane may prevent
penetration of antibacterial agents.
• It also prevents easy access of lysozyme
• Some bacteria have capsule and/or
flagella
• Two major classes: Gram positive
(Gram +) and Gram negative (Gram -).
• Gram’s stain is taken up by Gram +ve
• Gram –ve donot take gram’s stain
• In Gram –ve the membrane may
prevent penetration of antibacterial
agent
• Also prevents easy access of lysozme
• Bacterial & human cells use similar mechanism for energy from glucose
• If glucose oxidation is blocked bacteria can utilize other compds for energy

• Some pathways exist in pathogen but not human.

• Example: Folate biosynthesis
• Folate is required for DNA synthesis in both bacteria and human.
• Human cannot synthesize folate but most species of bacteria can.
• PABA is essential for synthesis of Folate.
• Sufonilamide is a structural analogue of PABA.
• Folate is required for DNA, RNA synthesis in Bacteria.
• Sulfonamides compete with PABA for the enzyme
dihydropteroate synthetase.
• Thus inhibit metabolism of bacteria
• They are bacteriostatic.
Pteridine is an aromatic chemical compound composed of fused pyrimidine and pyrazine rings
• Pyrimidine and purine analogues

• Fluorouracil (pyrimidine analogue) is used in cancer

chemotherapy.
• Cancer chemotherapy agents (purine analogue)
• Mercaptopurine
• Thioguanine
• Flucytosine (antifungal)
• is deaminated to FU in fungal cells
• to a lesser extent in human cells.
• 5-FU is converted intracellularly
to several active metabolites:
• Fluorodeoxyuridine
monophosphate (FdUMP),
• Fluorodeoxyuridine triphosphate
(FdUTP) and
• fluorouridine triphosphate (FUTP)

• Metabolites disrupt RNA

synthesis and
• Interferes with Thymidylate
Synthase.

Thymidylate synthetase catalyzes the conversion of deoxyuridine monophosphate (dUMP) to

deoxythymidine monophosphate (dTMP). Thymidine is one of the nucleotides in DNA. 
• Assembly of small molecules into macromolecules –
protein, RNA, DNA, polysaccharides and peptidoglycan.

• good targets for selective toxicity.

Peptidoglycan
Biosynthesis
&
Drug Targets
Step By Step Peptidoglycan Synthesis

1
Step NO: 1

UDP Is Attached With NAM

UDP-NAM
Step No: 2
L-Alanine
Five Amino Acids Are
Added Sequentially
D-Glutamic Acid
To UDP-NAM To Form
A Pentapeptide Side
Chain Meso-Diaminopimelic
Acid
UDP-NAM-
Pentapetide D-Alanyl-D-Alanine
 D-Alanyl-D-Alanine Formation

L-Alanine
cycloserine

Alanine Recemase

D-Alanine

D-Alanine Ligase

D-Alanyl-D-Alanine
Bactoprenol
Bactoprenol Is Attached To
The Cell Membrane.
Bactoprenol Is A
A Phosphate Group is Added
Lipid With Bactoprenol And
Formed
Chemical Structure: Bactoprenol Phosphate.
C55H92O P Bactoprenol

Bactoprenol Phosphate
Works As A Lipid Carrier.
 Step No: 3

UMP
Bactoprenol
P

UDP-NAM-Pentapeptide + Bactoprenol

NAM-Pentapeptide
 Step No: 4
Complex
Bactoprenol

Bactoprenol UDP

UDP-NAG NAM-Pentapeptide

NAG
NAM-Pentapeptide
Step No: 5

Cross The
Cell
Membrane

Complex
 Step No: 6
Bactoprenol Pyrophosphate

Complex Bactoprenol
 Peptidoglycan
Cross
Link Monomer Is Added
To The Growing End
Of The Existing
Petidoglycan

Vancomycin
Step No: 7
P

Bactoprenol Bactoprenol
Pyrophosphate Phosphate
Dephosphorylation

Bacitracin
• Bacitracin prevents phosphorylation of bactoprenol?

• Vancomycin – Blocks Cross linking?

• Cycloserine acts against two crucial enzymes
• alanine racemase &
• D-alanine:D-alanine ligase
Principles of Antimicrobial Therapy
Synthesis of peptidoglycan

• Cell wall of bacteria contains peptidoglycan

• In gram –ve bacteria – single thickness of peptidoglycan
• Gram positive bacteria as many as 40 layers of
peptidoglycan
• Peptidoglycan layer consists of multiple backbones of
amino sugars
• alternating NAG and NAM residues.
• NAM has short peptide side chains.
Synthesis of peptidoglycan (Contd.)

• Large insoluble peptidoglycan

layer is outside the cell
membrane.
• It has to be transported through
hydrophobic cell membrane
structure.
• A large 55 Carbon molecule lipid
carrier tows them across the
membrane.
Synthesis of peptidoglycan (Contd.)

• The peptidoglycan monomers are

synthesized in the cytosol
• Then attached to a membrane
carrier bactoprenol
• Bactoprenol is a large lipid carrier
contains 55 C atoms.
• Bactoprenol transports
peptidoglycan monomers across
the cell membrane where they are
inserted into the existing
peptidoglycan.
Peptidoglycan Synthesis
Step by step peptidoglycan synthesis

• Step 1: NAM is attached to UDP and a

pentapeptide.
• It is transferred to the C55 lipid carrier
in the membrane.
• There is release of UMP.
• This is followed by a reaction with
UDP-N-acetylglucosamine.
• Formation of disccharide pentapeptide
complex that is attached to the carrier.
• This is the basic building block of
peptidoglycan.
Step by step peptidoglycan synthesis (Contd.)
• The building block is now
transported out of the cell and
added to the growing end of the
peptidoglycan.
• Release of C55 lipid – two
phosphate attached.
• Lipid carrier loses one P and
available for another cycle.
• Cross link between the peptide side
chains of sugar residues in the
peptidoglycan layer.
 Step by step peptidoglycan synthesis (Contd.)

• Synthesis of peptidoglycan is a
vulnerable step.
• Can be blocked at several points
by antibiotic.
• Cycloserine – structural analogue
of D-alanine.
• Cycloserine prevents the addition
of two terminal alanine residues
to the initial tripeptide sidechain
on NAM by competitive
inhibition.
• Vancomycin inhibits the release
of the building block unit from
the carrier – preventing
addition to growing end of
peptidoglycan.
• Bacitracin interferes with the
regeneration of the lipid carrier
by blocking dephosphorylation.

• Penicillin, cephalosporins, and

other beta lactams inhibit the
final tranpeptidation by forming
covalent bond with PBP.
Protein synthesis in bacteria
• Protein synthesis takes place in the ribosome.
• Eukaryote and prokaryote ribosomes are different.
• This provides a basis for the selective antimicrobial actions of some
antibiotics.
• The bacterial ribosome consists of a 50S subunit and a 30S subunit.
• Mammalian ribosomes the subunits are 60S and 40S.
Protein synthesis in bacteria

• The other elements involved in peptide synthesis are

• mRNA, which forms the template for protein synthesis
• tRNA, which transfers the individual AAs to the
ribosomes.
• Ribosomes has THREE binding sites for tRNA, termed the
A,P and E sites.
• Antibiotics may affect protein synthesis.
Nucleic acid synthesis:

• N acids of the cell are DNA and RNA.

• Three types of RNA: mRNA, tRNA and Ribosomal
RNA, rRNA
• rRNA is an integral part of ribosome
• rRNa is necessary for ribosomal assembly
• Facilitate mRNA binding.
Nucleic acid synthesis (Contd.):

• DNA is the template for the

synthesis of DNA and RNA.
• It exists in the cell as double
helix.
• Each strand is a linear polymer
of nucleotides
 Nucleic acid synthesis (Contd.):
• Single strand DNA comprises alternating
sugar and phosphate groups with the base
attached.

• Specific hydrogen bonding between G & C

and between A & T on each strand
(Complementary base pairing) is the basis
of double stranded helical structure of
DNA

• DNA helix is itself further coiled.

 Nucleic acid synthesis (Contd.):
• Initiation of DNA synthesis requires
first the activity of a protein that
causes separation of the strands.
• The replication process inserts a
positive supercoil, which is relaxed
by DNA gyrase ( also called
topoisomerase II)
• During the synthesis of DNA,
nucleotide are added by base
pairing on the template.
• Condensation occurs by elimination
of two phosphate groups, catalysed
by DNA polymerase.
Nucleic acid synthesis (Contd.):
• RNA exists only in single-stranded from.
• The sugar moiety is ribose, and the ribonucleotides contain the bases
adenine, guanine, cytosine, and uracil (U).

• It is possible to interfere with nucleic acid synthesis in five different ways:

• by inhibiting the synthesis of the nucleotides
• by altering the base-pairing properties of the template
• by inhibiting either DNA or RNA polymerase
• by inhibiting DNA gyrase
• by a direct effect on DNA itself.
• Examples of drugs interfere with nucleic acid synthesis:

• by inhibiting the synthesis of the nucleotides

• by altering the base-pairing properties of the template
• Eg. Proflavine and Acriflavine
• by inhibiting either DNA or RNA polymerase
• Eg. Dactinomycin (actinimycin D), Rifamycin, Rifampicin, Aciclovir,
Zidovudine, Didanosine, Cytarabine, Foscarnet
• by inhibiting DNA gyrase: Fluoroquinolones (Cinoxacin, Nalidixic
acid, Ciprofloxacin, and Norfloxacin) and Doxorubicin (anticancer
agent)
• by a direct effect on DNA itself: Mitomycin, Bleomycin.
• Summary of the Action of Specific Agents

• Quinolones bind to a bacterial complex of DNA and DNA gyrase,

blocking DNA replication.
• Nitroimidazoles damage DNA.
• Rifampin blocks RNA synthesis by binding to DNA directed RNA
polymerase.
• Aminoglycosides, tetracycline, chloramphenicol, erythromycin, and
clindamycin all interfere with ribosome function.
• Sulfonamides and trimethoprim block the synthesis of the folate
needed for DNA replication
Penicillin binding Proteins
•Peptidoglycans are composed of chains of amino
sugars (NAM and NAG).

• They are crosslinked together by short AA chains

(Alanine and Glutamic acids).

•AAs are cross linked together by transpeptidase

enzymes
 PBP
•Penicillin-binding
proteins (PBPs) are a group
of proteins that are
characterized by their affinity
for and binding of penicillin
•They are a normal
constituent of many bacteria
 
 PBP

•PBPs are members of a

subgroup of enzymes
called transpeptidases.
•PBPs are involved in the
synthesis of peptidoglycan.
 
 PBP
•PBPs are characterized by their
affinity to bind the penicillin.
•Beta lactams bind to PBPs.
•Inhibition of PBP will lead to
irregularities in the cell wall structure
– eventually cell death.
 Antibiotics:
Cell wall synthesis
Inhibitors
Inhibitors of cell wall synthesis
• Some antibiotics selectively interfere with
synthesis of the bacterial cell wall.
• The cell wall is a polymer called peptidoglycan
• Peptidoglycans are composed of chains of
amino sugars (NAM and NAG).
• The units joined to each other by peptide cross-
link.
Inhibitors of cell wall synthesis
• Cell wall synthesis inhibitors inhibit the wall by
binding with protein binding site of the micro-
organisms.
• These class have no effect on those bacteria
that lacks cell wall (anaerobes) and bacteria in
dormant stage.
Beta-Lactam Antibiotics
• β-Lactam antibiotics are the most widely produced and used antibacterial drugs
in the world.

• β-Lactams are divided into several classes based on their structure and
function;

• and are often named by their origin, but all classes have a common β-Lactam
ring structure.

N
O
• Penicillin-binding proteins (PBPs) are bacterial
proteins that bind to penicillin and other
antibiotics of the β-lactam class.
• PBPs are generally enzymes involved in
peptidoglycan biosynthesis
• Contribute essential roles in bacterial cell wall
biosynthesis.
• PBPs bind β-lactam
antibiotics because
their chemical structure
is similar to that of the
sugar–amino acid
backbone that forms
peptidoglycan.
• Beta lactam anibiotics inhibit bacterial growth
by interfering with the transpeptidation
reaction of bac cell wall syn.
• PBP removes terminal alanine in the process
of forming a cross link with a nearby peptide
• Beta lactams are structural analogs the
natural D-Ala-D-Ala substrate, covalently bind
to the active site of PBPs.
• This inhibits peptidation reaction – synthesis
of peptidoglycan.
•Penicillins competitively inhibit penicillin-binding
proteins such as the enzyme DD-transpeptidase. 

•Inhibition of this process weakens the cell walls,

allowing an influx of water into the cell, which leads
to cell swelling and then cell lysis.

•However, some bacteria can produce the ß-

lactamase enzyme, which breaks down the ß-lactam
ring in the penicillin, resulting in resistance.
Bacterial Resistance to β lactams
• Bacteria have many methods with which to combat the
effects of β-lactam type drugs.

• Intrinsic defenses such as efflux pumps can remove the

β-lactams from the cell.

• β-Lactamases are enzymes which hydrolyze the amide

bond of the β-lactam ring, rendering the drug useless.

• Bacteria may acquire resistance through mutation at the

genes which control production of PBPs, altering the
active site and binding affinity for the β-lactam.
• Certain bacteria becomes resistant through
mechanism known as efflux.
• Efflux pump is a channel actively transport
antimicrobial out of the cell.
• Antimicrobial enters the bacterium through a
channel (Porin) and turned back out of the
bacteria by efflux pump.

• https://www.youtube.com/watch?
v=g9iOkXfTfFM
• Drug-modifying enzymes (beta-lactamases)
• Gram-positives(e.g., S. aureus) excrete the enzyme
• Gram-negative (e.g., E. coli) retain the enzyme in the periplasm
• Beta lactamase cleaves the beta lactam ring of penicillin
and cephalosporin.
• Staphylococci – principal bacterial species produce beta
lactamase
• Enzyme passes through the bacterial envelope and
• inactivates antibiotic molecules in the surrounding media.
• Gram negative bacteria can also produce beta
lactamase.
• Enzymes are produced constitutively.
• Enzyme does not inactivate the drug in the
surrounding medium
• It remains attached to the cell wall – prevent
access of the drug to the target sites.
Range of Activity
• β-Lactams can easily penetrate Gram (+)
bacteria, but the outer cell membrane of Gram
(-) bacteria prevents diffusion of the drug.
• β-Lactams also have difficulty penetrating
human cell membranes, making them
ineffective against atypical bacteria which
inhabit human cells.
• Any bacteria which lack peptidoglycan in their
cell wall will not be affected by β-lactams.
Toxicity
• β-Lactams target PBPs exclusively, and because
human cell membranes do not have this type of
protein.

• β-lactams are relatively non toxic compared to

other drugs which target common structures such
as ribosomes.

• About 10% of the population is allergic

(sometimes severely) to some penicillin type β-
lactams.
Antibiotics less susceptible to inactivation

• Semisynthetic penicillin (eg. Methicillin)

• New beta lactam antibiotics (monobactams and
carbapenems)
• Cephalosporins ( eg. Cephamandole)
Indications of Penicillin
• Skin & Soft Tissue Infection
• Boils, Abscess, Carbuncles etc.
• Respiratory Tract Infection
• Pneumonia, Sinusitis, Lung Abscess
• Gastrointestinal infections
• Bacterial diarrhea, Cholangitis, Typhoid etc.
• Genito-Urinary tract infection
• Gonorrhea, Cystitis, Urethritis etc.
• Other infections
• Septicemia, Meningitis etc.
Adverse Drug Reaction
• Hypersensitivity
• Diarrhea
• Nephritis
• Neurotoxicity
• Hematologic toxicities
• Cation toxicity
Cephalosporins
First-Generation Cephalosporins
Cephradine, Cephalexin, Cephadroxil, cephapirin
Second-Generation Cephalosporins
Cefuroxime, Cefamandole, Cefaclor
Third-Generation Cephalosporins
Cefotaxime, Cefixime, Ceftibuten, Ceftriaxone
Fourth-Generation Cephalosporins
Cefepime
Fifth-Generation Cephalosporins
Ceftaroline
Indications of Cephalosporins
• Urinary Tract Infections
• Mixed Infections
• Surgical infections
• Skin & Soft Tissue Infection
• Boils, Abscess, Carbuncles etc.
• Respiratory Tract Infection
• Pneumonia, Sinusitis, Lung Abscess
• Gastrointestinal infections
• Bacterial diarrhea, Cholangitis, Typhoid etc.
• Genito-Urinary tract infection
• Gonorrhea, Cystitis, Urethritis etc.
• Other infections
• Septicemia, Meningitis etc.
Adverse Drug Reaction
 Hypersensitivity
 Diarrhea
 Bleeding
 Nephritis
 Neurotoxicity
 Burning sensation
Carbapenems

Carbapenems are a potent class of β-

lactams which attack a wide range of
PBPs, have low toxicity, and are much
more resistant to β-lactamases than the
penicillins or cephalosporins.
Clinical Uses
• Active against Gram (-)aerobes only
• Alternative for penicillins ( piperacillin ) and
cephalosporins ( ceftazidime ) allergic pts
• Safe alternative to aminoglycosides, esp. in elderly and
pts with renal impairments
 Antibiotics:
Protein Synthesis Inhibitors
Protein synthesis inhibitors
• Antimicrobial action by targeting the bacterial ribosome
• Bacterial ribosome are smaller (70S) than human ribosome (80S)
• Subunits of Bacterial ribosome are 50S and 30S and human ribosome
60S and 40S
• These are mainly bacteriostatic rather than bactericidal
• Protein synthesis at a glance

• https://www.youtube.com/watch?v=oefAI2x2CQM
Tetracyclines
Broad-spectrum antibiotics.
Source: Streptomyces genus of Actinobacteria.

-The first of these compounds was chlortetracycline

followed by oxytetracycline and tetracycline.
Tetracyclines (Contd.)
•Tetracycline is indicated in respiratory diseases.
•Doxycycline is given once daily and may be used in patients with renal
impairment.
•Indicated in rickettsial and chlamydial infections, brucellosis, anthrax etc
•Respiratory tract infections
•The side effects include
 Gastrointestinal disturbances
 Vitamin B complex deficiency
 dental hypoplasia
 Bone deformities
 Phototoxicity
Mechanism of resistance
There are three types of tetracycline
resistance:

1)Tetracycline efflux.

2)ribosomal protection.

3) tetracycline inactivation.
Aminoglycosides
• Most commonly employed agents
• Gentamicin, tobramycin, amikacin

• Narrow-spectrum antibiotics

• Use – aerobic gram-negative bacilli

• Not absorbed from the GI tract

• Can cause toxicity to inner ear and kidney

https://www.youtube.com/watch?v=Y0tW1s5FQZ8
Fig. 86-1. Structural formulas of the major aminoglycosides.
Bacterial resistance
Bacterial resistance to aminoglycosides occurs via one of three
mechanisms that prevent the normal binding of the antibiotic
to its ribosomal target:
• Reduced uptake or decreased cell permeability
• Altered Ribosome Binding Sites
• Enzymatic Modification
 Streptomycin
• Used along with other antibiotics in
• Severe infections – tuberculosis, tularemia, endocarditis,
plague

Gentamicin
• Meningitis and infections of the blood, abdomen, lungs, skin,
bones, joints, and urinary tract.

Side effects of Aminoglycosides:

• Ototoxicity and Nephrotoxicity

• Rare: Paralysis due to Neuromuscular Blockade
Gentamicin (Garamycin)
• Used to treat serious infections caused by aerobic gram-negative
bacilli
• Pseudomonas aeruginosa
• Escherichia coli
• Klebsiella
• Serratia
• Proteus mirabilis
Other Aminoglycosides
• Tobramycin (Nebcin)
• Amikacin (Amikin)
• Neomycin
• Kanamycin (Kantrex)
• Streptomycin
• Paromomycin (Humatin)
Macrolides
• Erythromycin was the first macrolide. Other macrolides include:
• Clarithromycin
• Azithromycin
• Fidaxomicin
• Telithromycin
• Macrolides are active against most aerobic and anaerobic gram-
positive bacteria, although there is considerable variation as to potency
and activity.
• They are active against a limited range of Gram-negative organisms
(B. pertussis, H. influenzae etc.).
• Macrolides are used in the treatment of infections such as:
• Respiratory tract infections
• Skin and soft tissue infections
• Pneumonia – often added to a penicillin drug to cover atypical
organisms such as Legionella pneumophila and Mycoplasma
pneumoniae.
• Peptic ulcer disease – used in combination with a PPI and a penicillin
to eliminate Helicobacter pylori infection
• Side effects
• Side effects with macrolides include:
• GI effects – nausea, vomiting, abdominal pain, diarrhea
• Antibiotic-associated colitis
• Cholestatic jaundice
• QT interval prolongation – predisposing patients to arrhythmias
• Bacterial resistance to  Macrolide
• (1) through target-site modification by methylation or mutation
• (2) through efflux of the antibiotic, and
• (3) by drug inactivation.
• https://www.youtube.com/watch?v=oC21vLFtsjo
 Antibiotics:
Protein Synthesis Inhibitors
Protein synthesis inhibitors
• Antimicrobial action by targeting the bacterial ribosome
• Bacterial ribosome are smaller (70S) than human ribosome (80S)
• Subunits of Bacterial ribosome are 50S and 30S and human ribosome
60S and 40S
• These are mainly bacteriostatic rather than bactericidal
• Protein synthesis at a glance

• https://www.youtube.com/watch?v=oefAI2x2CQM
Tetracyclines
broad-spectrum antibiotics.
Source: Streptomyces genus of Actinobacteria.
-It is commonly used to treat acne, infection, and other infections
caused by bacteria.
-The first of these compounds was chlortetracycline followed by
oxytetracycline and tetracycline.
Mechanism of Action
Mechanism of resistance
There are three types of tetracycline
resistance:

1)Tetracycline efflux.

2)ribosomal protection.

3)tetracycline inactivation.
Aminoglycosides
• Most commonly employed agents
• Gentamicin, tobramycin, amikacin
• Narrow-spectrum antibiotics
• Bactericidal
• Use – aerobic gram-negative bacilli
• Can cause serious injury to inner ear and kidney
• Not absorbed from the GI tract
• Microbial resistance
Fig. 86-1. Structural formulas of the major aminoglycosides.
https://www.youtube.com/watch?
v=Y0tW1s5FQZ8
Mechanism of action of aminoglycosides.
• A, Protein synthesis begins with binding of the
50S and 30S ribosomal subunits to messenger
RNA (mRNA),
• followed by attachment of the first amino acid
of the new protein to the 50S subunit.
• As the ribosome moves down the mRNA strand,
additional amino acids are added to the growing
peptide chain. When the new protein is
complete, it separates from the ribosome and
the ribosomal subunits separate from the
mRNA.
 Mechanism of action of aminoglycosides.

B, Aminoglycosides bind to the 30S ribosomal subunit

and can thereby
(1) block initiation,
(2) terminate synthesis before the new protein is
complete, and
(3) cause misreading of the genetic code, which
causes synthesis of faulty proteins.
Bacterial resistance
Bacterial resistance to aminoglycosides occurs via one of three
mechanisms that prevent the normal binding of the antibiotic to
its ribosomal target:
(1)Efflux pumps prevent accumulation of the aminoglycoside in the
cytosol of the bacterium.
(2) Modification of the aminoglycoside prevents binding to the
ribosome.
(3)Mutations within the ribosome prevent aminoglycoside binding.
Gentamicin (Garamycin)
• Used to treat serious infections caused by aerobic gram-negative
bacilli
• Pseudomonas aeruginosa
• Escherichia coli
• Klebsiella
• Serratia
• Proteus mirabilis
• Adverse effects
• Nephrotoxicity
• Ototoxicity
Other Aminoglycosides
• Tobramycin (Nebcin)
• Amikacin (Amikin)
• Neomycin
• Kanamycin (Kantrex)
• Streptomycin
• Paromomycin (Humatin)
 Antibiotics:
Protein Synthesis Inhibitors
Protein synthesis inhibitors
• Antimicrobial action by targeting the bacterial ribosome
• Bacterial ribosome are smaller (70S) than human ribosome (80S)
• Subunits of Bacterial ribosome are 50S and 30S and human ribosome
60S and 40S
• These are mainly bacteriostatic rather than bactericidal
• Protein synthesis at a glance

• https://www.youtube.com/watch?v=oefAI2x2CQM
Tetracyclines
Broad-spectrum antibiotics.
Source: Streptomyces genus of Actinobacteria.

-The first of these compounds was chlortetracycline

followed by oxytetracycline and tetracycline.
Tetracyclines (Contd.)
•Tetracycline is indicated in respiratory diseases.
•Doxycycline is given once daily and may be used in patients with renal
impairment.
•Indicated in rickettsial and chlamydial infections, brucellosis, anthrax etc
•Respiratory tract infections
•The side effects include
 Gastrointestinal disturbances
 Vitamin B complex deficiency
 dental hypoplasia
 Bone deformities
 Phototoxicity
Mechanism of resistance
There are three types of tetracycline
resistance:

1)Tetracycline efflux.

2)ribosomal protection.

3) tetracycline inactivation.
Aminoglycosides
• Most commonly employed agents
• Gentamicin, tobramycin, amikacin

• Narrow-spectrum antibiotics

• Use – aerobic gram-negative bacilli

• Not absorbed from the GI tract

• Can cause toxicity to inner ear and kidney

https://www.youtube.com/watch?v=Y0tW1s5FQZ8
Fig. 86-1. Structural formulas of the major aminoglycosides.
Bacterial resistance
Bacterial resistance to aminoglycosides occurs via one of three
mechanisms that prevent the normal binding of the antibiotic
to its ribosomal target:
• Reduced uptake or decreased cell permeability
• Altered Ribosome Binding Sites
• Enzymatic Modification
Gentamicin (Garamycin)
• Used to treat serious infections caused by aerobic gram-negative
bacilli
• Pseudomonas aeruginosa
• Escherichia coli
• Klebsiella
• Serratia
• Proteus mirabilis
Other Aminoglycosides
• Tobramycin (Nebcin)
• Amikacin (Amikin)
• Neomycin
• Kanamycin (Kantrex)
• Streptomycin
• Paromomycin (Humatin)
Macrolides
• Erythromycin was the first macrolide. Other macrolides include:
• Clarithromycin
• Azithromycin
• Fidaxomicin
• Telithromycin
• Macrolides are active against most aerobic and anaerobic gram-
positive bacteria, although there is considerable variation as to potency
and activity.
• They are active against a limited range of Gram-negative organisms
(B. pertussis, H. influenzae etc.).
• Macrolides are used in the treatment of infections such as:
• Respiratory tract infections
• Skin and soft tissue infections
• Pneumonia – often added to a penicillin drug to cover atypical
organisms such as Legionella pneumophila and Mycoplasma
pneumoniae.
• Peptic ulcer disease – used in combination with a PPI and a penicillin
to eliminate Helicobacter pylori infection
• Side effects
• Side effects with macrolides include:
• GI effects – nausea, vomiting, abdominal pain, diarrhea
• Antibiotic-associated colitis
• Cholestatic jaundice
• QT interval prolongation – predisposing patients to arrhythmias
• Bacterial resistance to  Macrolide
• (1) through target-site modification by methylation or mutation
• (2) through efflux of the antibiotic, and
• (3) by drug inactivation.
• https://www.youtube.com/watch?v=oC21vLFtsjo
Inhibitors of Nucleic acid
synthesis
Nucleic acid synthesis:

• N acids of the cell are DNA and RNA.

• Three types of RNA: mRNA, tRNA and Ribosomal
RNA, rRNA
• rRNA is an integral part of ribosome
• rRNa is necessary for ribosomal assembly
• Facilitate mRNA binding.
Nucleic acid synthesis (Contd.):

• DNA is the template for the

synthesis of DNA and RNA.
• It exists in the cell as double
helix.
• Each strand is a linear polymer
of nucleotides
DNA Structure
DNA Unzipping by Helicase
• Enzyme called primase to start the
process.
• Primase make a small pieces of RNA
called a primer.
• This is the starting point of making the
new strand of DNA.
• DNA polymerase binds to the primer
and makes the new strand of DNA.
• The replication process inserts a
positive supercoil, which is relaxed by
DNA gyrase ( also called topoisomerase
II)
• One of the new strands of DNA
is the leading strand is made
continuously.
• DNA polymerase adding bases
one by one in the 5 to 3
direction.
• The other strand the lagging
strand cannot be made
continuously because it runs in
the opposite direction.
• DNA polymerase make this
strand in a series of small
chunks, called okazaki
fragments.
• The lagging strand is synthesized
discontinuously
• Primase synthesizes short RNA
primer.
• RNA prier is extended by DNA
polymerase to form Okazaki
fragment.
• Next primer is added further down
to the lagging strand.
• Another Okazaki fragment is made
and the process is repeated.
 DNA replication of the leading and lagging
strand
• The helicase unzips the double-stranded
DNA for replication, making a forked
structure.
• The primase generates short strands of
RNA that bind to the single-stranded DNA
to initiate DNA synthesis by the DNA
polymerase.
• This enzyme can work only in the 5' to 3'
direction, so it replicates the leading
strand continuously.
• Lagging-strand replication is
discontinuous, with short Okazaki
fragments being formed and later linked
together.progress. Nature 439, 542-543 (2006).
© 2006 Nature Publishing Group Bell, S. D. Molecular biology: Prime-time
• Once the new DNA has been made, the enzyme exonuclease removes
all the RNA primers from both strand of DNA.
• Another DNA polymerase enzyme then fills in the gaps that are left
behind with DNA.
• Finally the enzyme DNA Ligase seals up the fragments of DNA in both
strands to form a continuous double strand.
 Nucleic acid synthesis (Contd.):
• Initiation of DNA synthesis requires
first the activity of a protein that
causes separation of the strands.
• The replication process inserts a
positive supercoil, which is relaxed
by DNA gyrase ( also called
topoisomerase II)
• During the synthesis of DNA,
nucleotide are added by base
pairing on the template.
• Condensation occurs by elimination
of two phosphate groups, catalysed
by DNA polymerase.
Nucleic acid synthesis (Contd.):
• RNA exists only in single-stranded from.
• The sugar moiety is ribose, and the ribonucleotides contain the bases
adenine, guanine, cytosine, and uracil (U).

• It is possible to interfere with nucleic acid synthesis in five different ways:

• by inhibiting the synthesis of the nucleotides
• by altering the base-pairing properties of the template
• by inhibiting either DNA or RNA polymerase
• by inhibiting DNA gyrase
• by a direct effect on DNA itself.
• Examples of drugs interfere with nucleic acid synthesis:

• by inhibiting the synthesis of the nucleotides. Eg: 5FU

• by altering the base-pairing properties of the template
• Eg. Proflavine and Acriflavine
• by inhibiting either DNA or RNA polymerase
• Eg. Dactinomycin (actinimycin D), Rifamycin, Rifampicin, Aciclovir,
Zidovudine, Didanosine, Cytarabine, Foscarnet
• by inhibiting DNA gyrase: Fluoroquinolones (Cinoxacin, Nalidixic
acid, Ciprofloxacin, and Norfloxacin) and Doxorubicin (anticancer
agent)
• by a direct effect on DNA itself: Mitomycin, Bleomycin.
• Summary of the Action of Specific Agents

• Quinolones bind to a bacterial complex of DNA and DNA gyrase,

blocking DNA replication.
• Nitroimidazoles damage DNA.
• Rifampin blocks RNA synthesis by binding to DNA directed RNA
polymerase.
• Aminoglycosides, tetracycline, chloramphenicol, erythromycin, and
clindamycin all interfere with ribosome function.
• Sulfonamides and trimethoprim block the synthesis of the folate
needed for DNA replication
Quinolones
Introduction
• The quinolones have a number of advantages over other
classes of antibacterial agents.
• They are effective against many organisms.
• well-absorbed orally,
• well-distributed in tissues, and
• they have relatively long serum half-lives and
• minimal toxicity.
• Because of deep-tissue and cell penetration, they are useful for
urinary tract infections, prostatitis, infections of the skin and bones,
and penicillin-resistant sexually transmitted diseases.
The first-generation quinolones
 O O
F OH
HN
N N

• Norfloxacin, a fluoroquinolone with a broad spectrum of

antibacterial activity, was patented in 1978 .
• Between 1978 and 1982, many new fluoroquinolones
were prepared and patented. These fluoroquinolones
now classified as second-generation quinolones.
The second-generation quinolones
The third-generation quinolones
• A third advance was made in early 1990s. All third-
generation fluoroquinolones have significantly improved
activity against gram-positive bacteria, notably
streptococcus pneumoniae. Some of them have good
activity against anaerobes and atypical pathogens.
Generation Spectrum
Gram- but not Pseudomonas species
1st

Gram- (including Pseudomonas

species), some Gram+ (S. aureus)
2nd and some atypicals

Same as 2nd generation with extended

Gram+ and atypical coverage
3rd

Same as 3rd generation with broad

4th anaerobic coverage

*withdrawn from the market in 1999

Mechanism of action
Quinolones enter the cell by passive diffuse.
Intracellularly, they inhibit the synthesis of
bacterial DNA by interfering with the action
of DNA gyrase ， topoisomeraseⅣ.

DNA gyrase is an enzyme within the class

of topoisomerase
https://www.youtube.com/watch?v=5rw8kLZqTM8
Antimicrobial Activity of the Quinolones (oral)

Gram-positive Some Staphylococcus aureus,

bacteria Streptococcus pyogenes, Virdans
group streptococci, Streptococcus
pneumoniae
Gram-negative Neisseria spp. Haemophilus
bacteria influenzae
Many Enterobacteriaceae, Some
Pseudomonas aeruginosa
Anaerobic bacteria Some clostridia spp, Some
Bacteroides spp.

Atypical bacteria Chlamydia and Chlamydophilia,

Mycoplasma pneumoniae,
Legionella spp

Mycobacteria Mycobacterium tuberculosis,

Mycobacterium avium complex,
Mycobacterium leprae
Resistance Mechanisms
• Mutations that enhance antibiotic efflux capability
• Bacterial chromosomal mutations for genes that encode for bacterial DNA
gyrase and Topo IV
• Mutations in outer membrane porins (Gram-)
• Quinolones are broad-spectrum antibacterial agents, commonly used in both clinical and
veterinary medicine.
• Their extensive use has resulted in bacteria rapidly developing resistance to these agents.
• Two mechanisms of quinolone resistance have been established to date:
• alterations in the targets of quinolones, and
• decreased accumulation due to impermeability of the membrane and/or an overexpression of
efflux pump systems.
• Mobile elements carrying the qnr gene, which confers resistance to quinolones.
• These mobile elements have the potential for horizontal transfer of quinolone resistance genes.

• Journal of Antimicrobial Chemotherapy (2003) 51, 1109–1117 DOI: 10.1093/jac/dkg222

Advance Access publication 14 April 2003
MECHANISMS OF RESISTANCE TO QUINOLONES

• Changes in the protein targets.

• DNA gyrase
• Topoisomerase IV.

• Reduction in the accumulation of the quinolone.

- Decrease in permeability.
- Increase in active efflux system(s).

• DNA gyrase and topoisomerase IV protection - qnr gene