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Staphylococcus aureus…………quickly posed a problem
Produce a B-lactamase (Penicillinase)
- Plasmid mediated (easily spread)- Secreted into the surrounding medium- Destroyed the Penicillin before it could reach the PBP’s
S
O
S
O
S
O
ON
SNH
COOH
CH3
CH3
C
O
Isoxazoyl Penicillins
O
N
CH3
R1
R2
R1 R2
Oxacillin H HCloxacillin Cl HDicloxacillin Cl Cl
If chemical modification can overcome B-lactamase activity
Maybe chemical modification can also increase spectrum of activity ?
ON
SNH
COOH
CH3
CH3
C
ONH2
Ampicillin
Aminopenicillins
- Modified to broaden their spectrum of activity- better binding affinity to the PBP’s of
Enterococci ListeriaSome Gram –ve bacteria
- But a cost of slight decreased activity against Streptococci-S. pneumonia / Group A strept
- Not stable to the B-lactamase produced by S. aureus
- Inactivated by many of the B-lactamases produced by Gram –ves (limited gram negative coverage)
Amino-Penicillin
• Amoxicillin
• Ampicillin
• Bacampicillin
First penicillins discovered to be active against gram negative rods like E. coli and H. Influenzae.
Amino-Penicillin
• Same coverage like Pen VK plus:
- Listeria monocytogenes
- Enterococcus
- Proteus mirabilus
- E coli
- H. flu
Amino-Penicillin
• Amoxicillin is more completely absorbed than Ampicillin.
• Serum levels are twice as high.
• Small amount is left in GI tract, so less diarrhea.
• However, more complete absorption makes it less effective for Shigella enteritis.
• Both have same antibacterial spectrum.
• Bacampicillin is more expensive and no advantage.
Amino-Penicillin
Primarily used for: • Otitis media• Sinusitis• Bronchitis• Urinary tract infection esp. Enterococcus• Bacterial diarrhea • Salmonella infection• Shigella infection.
H. Influenzae and E. Coli are increasingly becoming resistant.
Maybe if we change its structure a lot…..
…we will get even more gram negative coverage !
Carboxypenicillins
Carbenicillin
-1st penicillin developed with expanded gram –ve activity that included anti-pseudomonal activity
-But decreased activity against Streptococci and Enterococci
-Required large doses to be effective clinically- too toxic to be used clinically
-Replaced by the next drug developed in this class…Ticarcillin
Ureidopenicillins
- similar to Ampicillin wrt Streptococcal activityEnterococcal activity
- Better anti-pseudomonal activity then Ticarcillin- Better Klebsiella activity then Ticarcillin (75% vs 5%)
- Not orally absorbed thus available only IV
3 preparations Azlocillin (no longer available)Mezlocillin (USA)Piperacillin (Canada / USA)
Piperacillin is also available as a combination with a B-lactamase inhibitor to increase its spectrum of activity(Piperacillin + Tazobactam = Pip/Tazo)
ON
SNH
COOH
CH3
CH3
C
O
Penicillin G
ON
SNH
COOH
CH3
CH3
C
O
Piperacillin
NHNN
CH3
O O
C
O
5 Classes of Penicillins
Natural PenicillinsPenicillin G / Penicillin V
Penicillinase Resistant PenicillinsMethicillinNafcillinIsoxazoly Penicillins (Cloxacillin / Dicloxacillin / Oxacillin / Flucloxacillin)
AminopenicillinsAmpicillin / Amoxicillin
CarboxypenicillinsTicarcillin
UreidopenicillinsPiperacillin / Mezlocillin / Azlocillin
B-lactamases
Chromosomal Plasmid
Inducible Constituitive
High [ ] High [ ] Low [ ]
TEM 1-27SHV 1-8OXA 1-3PSE 1-5
Can NOT be overcome by Can be overcome byB-lactam – B-lactamase Inhibitor B-lactam – B-lactamase InhibitorCombinations Combinations
SPACESerratiaPseudomonasAcintobacterCitrobacterEnterobacter
Antibiotics
Biosynthetic Chemical
Penicillin(1945)
Antibiotics
Biosynthetic Chemical
Penicillin(1945)
Chemical ModificationSearch for otherCompounds
We like to think we are smart
Chemical Manipulation
Nature has been doing chemical modifications for millions of years
Bacteria have been fighting each other since before we evolved
There have been many chemical modifications
ON
SR
COOH
CH3
CH3
B-lactam
ON
SR
COOH
CH3
CH3
ON
CR
COOH
CH3
CH3
B-lactamCarbepenem
Carbapenems
1st isolated from Streptomyces cattleya in 1976
Base compound was thienamycin - methylene replacement for the Sulphur in the 5 membered ring
ON
SR
COOH
CH3
CH3
ON
CR
COOH
CH3
CH3
B-lactamCarbepenem
Carbapenems
- stable to B-lactamases
- due to the side chain being in a trans rather then the typical cis configuration seen in B-lactams
ON
S
ON
B-lactam Carbapenem
R R
2 Compounds in clinical use :
ImipenemMeropenem
Imipenem Meropenem
Imipenem
Spectrum of Activity
Gram +ve cocci- Staphylococcus aureus- Streptococci sp- S. pneumoniae- Enterococci
Gram –ve rods- except Pseudomonas cepacia and Xanthomonas maltophilia
Anaerobes- except Clostrium difficile and a % of Bacteroides sp
Mechanism of Action- binds to the PBP’s leading to cell lysis
Considered Bacterocidal (except for Enterococcus – bacteriostatic)
Resistance- not due to the typical B-lactamases
1. Enzyme that will hydrolyze the imipenem2. Loss of an outer membrane protein that would otherwise facilitate entry
ON
SR
COOH
CH3
CH3
PenicillinO
N
SR
COOH
CH3
CH3
ON
CR
COOH
CH3
CH3
O
R
N
S
COOH
R
Carbapenem
Side ChainModifications
Cephalosporin
Cephalosporins
1940’s Cephalosporium acremonium was isolated from the seawaterAt the harbour sewage outlet of Cagliari, Sardinia
Produced a substance that inhibited the growth of both gram +ve and gram –ve bacteria
1948 a culture of the fungus C. acremonium was sent to Oxford
3 antimicrobial substances produced by this fungus were identified
Cephalosporin P gram +ve activity onlyCephalosporin N re-identified as a penicillinCephalosporin C foundation for current Cephalosporin family
Cephalosporin C
- B-lactam ring fused to a 6 membered dihyrdothiazine ring
Mechanism of Action
Binds to PBP’s and interferes with synthesis of the peptidoglycancell wall
Bactericidal
Stable to many B-lactamases produced by gram +ve and gram –ve’s
Better ability to penetrate the outer LPS membrane of gram –ve bacteria
Gram –ve Gram +ve
LPS
Peptidoglycan
Cell membrane
Cell Memebrane
Cell Wall
Lipopolysaccharide (LPS)
PBP’s
B-Lactamases
Mechanisms of Resistance
1. Alteration of the PBP target2. Production of B-lactamases that inactivate cephalosporins
(Cephalinosporinases)3. Decreased ability of the Antibiotic to reach its target
(LPS of gram –ve bacteria)
Decreased affinity of PBP’s to bind cephalosporins are seen in
1. Streptococcus pneumoniae2. Haemophilus influenzae3. Neisseria gonorrhea4. MRSA
Major mechanism of resistance in gram +ve bacteria
Cephalosporinases (serine proteases) hydrolyze the amide bond of the B-lactam ring thus inactivating the antibiotic
Major mechanism of resistance in gram –ve bacteria
Can be encoded chromosomally or on plasmidsCan be constitutive or inducible
Effectiveness depends onAffinity of the Cephalosporinase for the CephalosporinConcentration of the Cephalosporinase producedConcentration of the Cephalosporin present
Plasmid mediated B-lactamases are often produced in large numbers
Number of different classes (TEM, SHV, etc)
Mutations lead to B-lactamases with increased spectrum of activity
ESBL’s (Extended Spectrum B-lactamases)- resistance to the 3rd generation cephalosporins- also will destroy the monobactams (Aztreonam)- however the Carbapenems are not affected (Imipenem / Meropenem)
Classification – based on the spectrum of activity
1st generation : gram +ve cocci
2nd generation : variable g +ve but increased gram –ve rod activity
3rd generation : variable g +ve but greatly increased g -ve activity
4th generation : g +ve and increased g -ve activity
0102030405060708090
100
1stGeneration
2ndGeneration
3rdGeneration
4thGeneration
Gram +veGram -veAnaerobic
1st Generation Half Life Peak Protein CSF [ ] Bound Penetration
Cephalothin (Ceporacin) IV 1hr 30 70 -Cefazolin (Ancef) IV 1hr 80 80 -Cephalexin (Keflex) po 1hr 18 10 -Cefadroxil (Duricef) po 1hr 16 20 -
2nd Generation Cefoxitin (Mefoxin) IV 0.8 hr 150 70 -Cefotetan (Cefotan) IV 3.5 hrs 230 90 -Cefuroxime (Kefurox/Ceftin) IV / po 1.3 hrs 100 35 1-2/-Cefaclor (Ceclor) po 0.8 hrs 13 25 -Cefprozil (Cefzil) po 1.2 hrs 10 42 -
3rd GenerationCefotaxime (Claforan) IV 1.0 hrs 130 35 5.6-44Ceftriaxone (Rocephin) IV 8 hrs 250 90 1.2-39Ceftizoxime (Cefizox) IV 1.7 hrs 1330 30 0.5-29Ceftazidime (Fortaz) IV 1.8 hrs 160 17 0.5-30
4th GenerationCefepime (Maxipime) IV 2.1 hrs 130 20 3.3-5.7
1st Generation Half Life Peak [ ] Protein Bound
Cephalothin (Ceporacin) IV 1hr 30 70 %Cefazolin (Ancef) IV 1hr 80 80 %
Cephalexin (Keflex) po 1hr 18 10 %Cefadroxil (Duricef) po 1hr 16 20 %
What does this mean ? …..
Best 1st Generation Oral Drug is Cephalexin (Keflex)- higher peak concentration- less protein binding-- means more free drug to act on bacteria
Best 1st Generation IV drug is Cefazolin (Ancef)- higher peak concentration- even though more is protein bound (80vs70%), the higher peak means..-- more free drug to act on bacteria
NO CSF Penetration thus do not use in Meningitis
2nd Generation Half Life Peak Protein CSF [ ] Bound Penetration
Cefoxitin (Mefoxin) IV 0.8 hr 150 70 -Cefotetan (Cefotan) IV 3.5 hrs 230 90 -Cefuroxime (Kefurox/Ceftin) IV / po 1.3 hrs 100/9 35 1-2/-Cefaclor (Ceclor) po 0.8 hrs 13 25 -Cefprozil (Cefzil) po 1.2 hrs 10 42 -
Cefoxitin
Cefuroxime
Cefaclor
Cefprozil
3rd Generation Half Life Peak Protein CSF [ ] Bound Penetration
Cefotaxime (Claforan) IV 1.0 hrs 130 35 5.6-44Ceftriaxone (Rocephin) IV 8 hrs 250 90 1.2-39Ceftizoxime (Cefizox) IV 1.7 hrs 1330 30 0.5-29Ceftazidime (Fortaz) IV 1.8 hrs 160 17 0.5-30Cefixime (Suprax) po 3.5 hrs
Cefotaxime
Ceftriaxone
ON
SR
COOH
CH3
CH3
PenicillinO
N
SR
COOH
CH3
CH3
ON
CR
COOH
CH3
CH3
O
R
N
S
COOH
R
Carbapenem
Side ChainModifications
Cephalosporin
ON
SR
COOH
CH3
CH3
PenicillinO
N
SR
COOH
CH3
CH3
ON
CR
COOH
CH3
CH3
O
R
N
S
COOH
R
Carbapenem
Side ChainModifications
Cephalosporin
Monobactam
Monobactams
Isolated from Chromobacterium violaceum in 1981
Monocyclic B-lactam antibiotic
No activity against gram +ve bacteria or anaerobes
Binds to PBP’s of gram –ve bacteria only
Hydrolyzed by cephalosporinases ofPseudomonas cepaciaXanthomonas maltophiliaAcinitobacterKlebsiella oxytocaHaemophilus
Pharmacology
-no oral absorption thus available as IV formulation only-Renal clearance
Complications
-mild rash-Mild transaminitis-NO MAJOR SIDE EFFECTS
Lack of cross reaction with other B-lactam antibiotics thuscan be used in Pen/Ceph allergic patients
Aztrenoam
-monobactam in clinical use
Limited to Gram –ve infections only
Penicillins
Carbepenems
Monobactams
Cephalosporins
B-lactamase Inhibitors
StructuralOverview
Antibiotics
Biosynthetic Chemical
Penicillin(1945)
Chemical ModificationSearch for otherCompounds
Antibiotics
Biosynthetic Chemical
Penicillin(1945)
Chemical ModificationSearch for otherCompounds
B-lactam AntibioticsDifferent Mechanisms
CarbapenemsMonobactamsCephalosporins
Glycopeptides
Glycopeptides
1st compound was isolated fromStreptomyces orientalis in 1956(bacteria)
Complex structure- amino acids + sugars
Vancomycin
Mechanism of Action :
Inhibit cell wall synthesis
- binds to peptidoglycan precursors
- blocks additional polymer extension
N-acetylglucosamine
N-acetylmuramic acid
d-ala
L-glu
Lys
d-ala
d-alaCell membrane
Cellwall
Transpeptidases (PBP’s)
N-acetylglucosamine
N-acetylmuramic acid
d-ala
L-glu
Lys
d-ala
d-ala
N-acetylglucosamine
N-acetylmuramic acid
d-ala
L-glu
Lys
d-ala
d-ala
N-acetylglucosamine
N-acetylmuramic acid
d-ala
L-glu
Lys
d-ala
d-ala
N-acetylglucosamine
N-acetylmuramic acid
d-ala
L-glu
Lys
d-ala
d-ala
N-acetylglucosamine
N-acetylmuramic acid
d-ala
L-glu
Lys
d-ala
d-ala
N-acetylglucosamine
N-acetylmuramic acid
d-ala
L-glu
Lys
d-ala
d-ala
N-acetylglucosamine
N-acetylmuramic acid
d-ala
L-glu
Lys
d-ala
d-ala
Mechanism of actionof Vancomycin
Vancomycin blocks cell wall synthesisBy binding to the d-alanyl-d-alanine site on the growing peptidoglycan chain
Vancomycin
Useful drug to treat B-lactam resistant staphylococcus aureus
Staphylococcus aureus
No b-lactamase B-lactamase Alter PBP’s
Penicillin Cloxacillin Vancomycin
(Penicillinase)
(MRSA)
Vancomycin
Useful drug to treat B-lactam resistant enterococcus
Enterococcus species
No b-lactamase B-lactamase Alter PBP’s
Ampicillin Vancomycin
Resistance to Vancomycin
1. Change in d-alanyl-d-alanine precursors - Van A, B, C mutations of VRE
2. Excess cell wall production- VISA
3. Biofilm production- seen on prosthetic devices /foreign bodies- Biofilms produced by bacteria impair the penetration of
the glycopeptide to the bacterial cells
4. Gram negatives constitutively resistant (LPS)
N-acetylglucosamine
N-acetylmuramic acid
d-ala
L-glu
Lys
d-ala
d-alaCell membrane
Cellwall
Transpeptidases (PBP’s)
d-lactate
N-acetylglucosamine
N-acetylmuramic acid
d-ala
L-glu
Lys
d-ala
d-lactate
Mechanism of resistance to Vancomycin
VRE Gene Complex
Van H gene- synthesizes d-lactate
Van A gene- binds d-lactate to d-alanine
Van X gene- hydrolyzes d-ala-d-ala
Van R & S genes- regulatory gene regions
Van Y& Z genes- accessory proteins
Antibiotics
Biosynthetic Chemical
Penicillin (1945)
Chemical modificationSearch for similar compounds
Antibiotics
Biosynthetic Chemical
B-lactam based antibiotics- Penicillins- Carbapenems- Monobactams- Cephalosporins
Antibiotics
Biosynthetic Chemical
B-lactam based antibiotics- Penicillins- Carbapenems- Monobactams- Cephalosporins
Vancomycin (1956)
Chemical modificationSearch for similar compounds
Naturally occuring glycopeptides
Vancomycin Streptomyces orientalis
Teicoplanin (Targocid) Actinoplanes teichomyceticus
Daptomycin (Cubicin) Streptomyces roseosporus
Ramoplanin Actinoplanes ATCC 33076
Semisythetic glycopeptides (2nd Generation)
Oritavancin Dalbavancin Telavancin
Glycopeptide Antibiotics
Glycopepetides Lipopeptides Lipoglycopeptides
Daptomycin(Cubicin)
(LY146032)
VancomycinTeicoplanin
Ramoplanin
Oritavancin (LY33328)
Dalbavancin
Telavancin
Inhibition of cell wall synthesis+
Increase cell membrane permeability
Inhibition of cell wall synthesisCidal
Semisynthetic derivatives
Teicoplanin Dalbavancin
Vancomycin Oritavancin
Role of the newer glycopeptide antibiotics….
Combat emerging resistance of
MRSA
VRE
Biosynthetic Antibiotics that inhibit protein synthesis
Aminoglycosides1943
Macrolides1952 Tetracyclines
1953
Lincosamides1962
Stretpogramins1953