antimicrobial medications. antibiotics antimicrobial drugs naturally produced by microorganisms –...
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Antimicrobial Medications
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Antibiotics• Antimicrobial drugs naturally
produced by microorganisms– Penicillium species: Penicillins– Cephalosporium specis:
cephalosporins– Streptomyces species:• lincosamides, aminoglycosides,
tetracyclines, chloramphenicol
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Features of antimicrobial drugs
• Selective toxicity– Therapeutic index
• Antimicrobial action– Bactericidal– Bacteristatic
• Spectrum of activity– Broad spectrum– Narrow spectrum
• Combination effects– Antogonistic– Synergistic– Additive
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Pharmacokinetics: what happens to the drug in the body?
• Absorption• Tissue distribution• Metabolism• Route of excretion• Rate of elimination
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Adverse effects• Adverse drug reaction• Toxic effects• Suppression of normal
microbiota
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Mechanisms of antimicrobial drugs
• Inhibition of cell wall synthesis• Inhibition of protein synthesis• Inhibition of nucleic acid synthesis• Inhibition of biosynthetic pathways • Disruption of cell membrane integrity
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Targets of Cell Wall Synthesis
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Penicillin
• Inhibits formation of tetrapeptide side chains
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How organisms degrade penicillins
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Family of Penicillins
• Natural penicillins• Penicillinase-resistant penicillins• Broad-spectrum penicillins• Extended-spectrum penicillins• Penicillins plus beta-lactamase inhibitors
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Family tree of penicillins
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β-lactams
• Penicillins• Cephalosporins• Carbapenems• Vancomycin• Bacitracin
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Cephalosporins
• Derived from fungus, Acremonium cephalosporium
• Chemical structure makes them resistant to beta-lactamase: low affinity for penicillin binding proteins
• Grouped into first, second, third, and fourth generation cephalosporins
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Vancomycin
• Binds to the terminal amino acids of the peptide chain of NAM molecules, blocks peptidoglycan formation
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Antibiotics that inhibit protein synthesis
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Oxazolidinones
• Reversibly bind to the 50S subunit, interfere with initiation of protein synthesis
• Used for treating gram positive infections resistant to Beta-lactam drugs and Vancomycin
• Ex: Linezolid
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Aminoglycosides
• Bactericidal • Irreversibly bind to 30S ribosome, cause
misreading of the mRNA• Transported into cells that actively respire (not
effective against ananerobes, streptococci, enterococci)
• Ex: streptomycin, gentamicin, tobramycin
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Tetracyclines & Glycylcyclines
• Bind reversibly to 30S, block attachment of the tRNA to ribosome
• Actively transported into bacterial cells• Effective against gram positive and gram
negative• Resistance: due to decrease in uptake or
increase in excretion• Ex: Doxycycline
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Macrolides
• Reversibly bind to the 50S, prevent continuation of protein synthesis
• Drug of choice for patients allergic to penicillins
• Not good for Enterobacteriaceae• Ex: Erythromycin, Azithromycin• Resistance: enzymes that alter drug,
decreased uptake
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Inhibition of protein synthesis: Chloramphenicol
• Rare side effect = irreversible bone marrow suppression
• Banned in food animals• Making a come-back in companion animal
medicine due to effectiveness against multi-drug resistant staphylococci
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Antibiotics that inhibit nucleic acid synthesis
• Fluoroquinolones– Interferes with function of topoisomerase
• Rifamycins– Blocks prokaryotic RNA polymerase from initiating
transcription
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Antibiotics that inhibit biosynthetic pathways
• Sulfonamides• Trimethoprims
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Sulfonamides (sulfa drugs)
• First synthetic drugs to treat microbial infections
• Used to treat urinary tract infections (UTIs)• Combination of trimethoprim and
sulfamethoxazole (TMP-SMZ) example of synergism
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Drugs used together inhibit folic acid synthesis
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Tests for microbial susceptibility
• Kirby-Bauer (disk diffusion method)
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Tests for microbial susceptibility
• Minimum Inhibitory Concentration: MIC– Grow bacteria in a serial dilution of the
antimicrobial being tested– Fixed concentration of bacterial cells– Observation of turbidity after 16 hrs-24 hrs of
growth– Lowest concentration of drug that inhibits growth
= MIC
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Minimum Inhibitory Concentration
• Manual broth dilution method• Automated broth dilution method• E-test
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Determining the Minimum Inhibitory Concentration (MIC)
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Automated MIC
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E-test for MIC
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Zone size & MIC values
• Raw data• Meaningless without interpretation• Correlation of in vitro results with achievable
levels of drug concentration in a live patient• Correlation with actual clinical outcome
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What resistance looks like…
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Mutant Prevention Concentration?
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Mechanisms of acquired drug resistance
• Destruction or inactivation of the drug: drug inactivation enzymes
• Alteration of target molecule (mutation)
• Decreased uptake: alteration of porins
• Increased elimination: efflux pumps
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Acquiring resistance
• Spontaneous mutation• Gene transfer– R plasmids
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Emerging antimicrobial resistance
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Streptococcus pneumoniae
• Altered penicillin binding proteins– DNA-mediated transformation
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Enterococcus species
• Gram positive enteric cocci; facultative anaerobes; formerly classified as Group D streptococcus
• Common cause of nosocomial infections– Enterococcus faecalis,
Enterococcus faecium• Intrinsic resistance:• Acquired resistance
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Mycobacterium tuberculosis
• Multidrug-resistant M. tuberculosis– Resistance to isoniazid
& rifampin• Extensively drug-
resistant M. tuberculosis– Resistance to isoniazid
& rifampin + 3 or more of the 2nd line drugs
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Enterococcus species: intrinsic resistance
• Low affinity of penicillin binding proteins for many β-lactam antibiotics, esp. cephalosporins
• Resistance to potentiated sulfonamides (i.e., trimethoprim-sulfa): able to utilize external sources of folate
• Low permeability for aminoglycosides– Treatment with a cell-wall active drug such as
ampicillin is synergistic (allows the drug to get into the cell) UNLESS high-level gentamicin resistance is present
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Enterococcus species: acquired resistance
• High-level gentamicin-resistance: plasmid-encoded inactivating enzymes
• Tetracycine resistance: efflux pumps, ribosomal protection
• Macrolide resistance: efflux pumps• Vancomycin resistance: altered drug binding
site on cell wall
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Enterobacteriaceae
• Gram negative enteric rods
• Intrinsic resistance to many drugs due to outer membrane
• β-lactamases: enzymatic inactivation of the lactam ring
• Extended spectrum β-lactamases (ESBL+)
• Carbapenem-resistance: enzymatic inactivation
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Staphylococcus species
• Staph aureus• Staph pseudintermedius• Staph schleiferi• Methicillin-resistant staph: penicillinase +
altered penicillin-binding proteins with low affinity for β-lactam drugs (mecA gene on R plasmid)
• Vancomycin-resistant staph
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Methicillin-resistant staphylococci• MRSA: methicillin-resistant Staph aureus– drug resistance + increased pathgenicity
• MRSP: methicillin-resistant Staph pseudintermedius– Acquisition of drug resistance is not associated
with acquisition of new virulence factors• MRSS: methicillin-resistant Staph scheiferi– Drug resistance/no new virulence factors
• Coagulase-negative MRS
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Coagulase test
• Tests for coagulase enzyme = virulence factor produced by Staphylococcus aureus, Staph. pseudintermedius and Staph. schleiferi subspecies coagulans
• Important in differentiating potentially pathogenic from non-pathogenic species of staphylococci
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Coagulase enzymes
• Bound coagulase (“clumping factor”) – attached to bacterial cell wall– Coagulase enzyme + fibrinogen in plasma → fibrin
clot surrounding bacteria: prevents antibody and complement binding, prevents phagocytosis, protects from NETs
• Free coagulase – secreted enzyme– Coagulase enzyme + CRF → conversion of
prothrombin to thrombin and fibrinogen to fibrin
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Coagulase slide test
• Rabbit plasma + bacteria: agglutination within 1-2 minutes = positive result– Detects only bound coagulase– False negatives or equivocal results are common– Negative or equivocal tests have to be confirmed
with tube test
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Coagulase tube test
• Rabbit plasma + bacteria: coagulation of the plasma = thickening OR formation of fibrin clumps or threads– Standard practice = read at 4 hrs, if negative
recheck at 24 hrs• Tests not read at 4 hrs that are negative at > 4 hrs will
have to be repeated because early positive results may revert to a negative result
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Coagulase negative staph
• Common isolates from skin cultures• Non-pathogenic commensuals• Rarely part of mixed population in deep skin/
wound infections (furuncles)• Rarely cause bacteremia or other systemic
infections in immune-compromised individuals
• Commonly carry plasmids with mecA gene
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MRS: colonization vs. infection
• Sharing of plasmids + high antimicrobial use• Selecting for MRS population• Increasing % of staphylococcal isolates from
non-lesional skin and nasal mucosa are methicillin resistant
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Responsible drug use
• Use vs misuse of antimicrobial drugs• Responsibilities of health care professionals?• Responsibilities of patients?• Responsibilities of pet owners?• Public education• Over the counter antimicrobial drugs– Developing countries– US feed stores
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Antimicrobial Stewardship
• Increasing drug resistance• Fewer drugs in development• Drugs being developed don’t have novel
targets• Drugs being developed are broad spectrum• “Bad Bugs, No Drugs” task force 10x20
initiative
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Antimicrobial Stewardship
• 4 D’s of antimicrobial therapy– Right Drug, – Right Dose, – De-escelation to pathogen directed therapy – Right Duration of therapy
• Prevent overuse, misuse and abuse• Minimize the development of resistance