dr. berek zsuzsa - semmelweis...
TRANSCRIPT
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Antimicrobial chemotherapy
- history
- principles and practice
- mode of action, resistance
Dr. Berek Zsuzsa01 October 2013
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How to kill Microbes?
Extracorporal
sterilisation
disinfecting
prevention
Intracorporal
Antimicrobial drugs
chemotherapy
antibiotics
treatment(prevention)
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Historical overviewexperimental, „mold-on-bread”
quinine, emetine
Ehrlich 1906 – 1910- Arsphenamines, aniline dyes
(sleeping sickness, trypanosomes)
- 606th drug SALVARSAN
Domagk 1930-s sulphonamides
Fleming 1928 – 1940Penicillin et al.
Waksman 1950-sstreptomycin + aminoglycosides
www.nobelprize.org
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„The father of chemotherapy”
1854 - 1915
www.nobelprize.org, www.germannotes.com, www.chemheritage.org www.dw-world.de
aerzteblatt.lnsdata.de, 1909 www.paul-ehrlich-symposium-2004.de
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www.dhm.de, www.rpsgb.org.uk,
www.personal.psu.edu
www.britannica.com, www.nobelprize.org
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www.uni-muenster.de
www.nobelpreis.org,
www.nobelprize.org
Gerhard Domagk
1895 - 1964
sulfonamides
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Sir Alexander
Fleming
1881 - 1955www.nobelprize.org, www.workersforjesus.com
www.gesundheit.de
Penicillin
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www.nobelprize.org, www.britannica.com
www.asap.unimelb.edu.au
Sir Howard Walter Florey
1898 - 1968
Ernst Boris Chain
1906 - 1979
Nobel prize
1945
Fleming
Florey
Chain
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Selman Abraham Waksman
1888 - 1973
… and Fleming
Nobel prize
1952
Streptomycin
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Antimicrobial drugs
Chemotherapy- drugs produced in laboratory
Antibiotics- produced by other micro-organism
Principle: selective toxicity (Ehrlich):
Antimicrobial drug should be
toxic to the (pathogen) microbe and
possibly harmless to the host (human being)
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Chemotherapeutical index:
dosis tolerata maxima
dosis curativa minima
The drug should be tolerated by the HOST
as high dose as possible, and cure the
HOST as low dose as possible.
Ci=
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Kais
er’
s A
bb.
4.2
7
Principles of antimicrobial treatment
HOST
DRUG
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Principles of antimicrobial treatment
correct indication„when to give?”
- in order to: TREAT or AVOID an infection
„what to give?”
the most suitable
1. the most effective one
2. the less toxic one
3. (the cheapest)
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Ad 1. effectiveA/ antimicrobial activity
- spectrum = against which species is it effective?
- numerically expressed: MIC, MBC
(minimal inhibitory/bactericidal concentration)
the sensitivity of a bacterium can be
detected in vitro
Principles of antimicrobial treatment
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B/ pharmacokinetic features
selective toxicity (Ad 2.)Side effects: - kidney
- liver
- bone marrow
(- nerves, GI)
C/ resistance
Principles of antimicrobial treatment
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„how much to give”
the satisfactory doseis the multiple amount of MIC at the locus of infection!
Dosage: - age
- liver and kidney functions
- body weight and hight
- pregnancy
„how long to give?” as long as there is no danger of relapseacute infection: min. 5 days
severe infection: 8-14 days
sepsis/endocarditis: 3-4-6 weeks, tbc: 9-12 months
Principles of antimicrobial treatment
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„Magic bullets...”Antibiotic tablets - per os application…
sensitive HALT!
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Effect of antimicrobial drugs on bacterium cell
cell wall
membrane
DNA
proteinsynthesis
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Antimicrobial drugs
I. Cell wall synthesis inhibitionBeta lactam drugs
1. penicillines
amino-, carboxi-, ureido
and
anti-staphylococcal penicillines
2. cephalosporines
generations: I., II., II., IV.
3. others
(monobactam, carbapenem)
www.med.sc.edu:85
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II. Cell membrane destruction
Polymyxin-B and - M
III. Nucleic acid level• Quinolons, fluoroquinolons (gyrase inhibitors)
• metronidazole = Klion®
(DNA damage by toxic metabolites)
Antimicrobial drugs
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IV. Protein synthesis inhibition- 30s ribosome subunit
Tetracyclines
Aminoglycosides
- 50s ribosome subunit
chloramphenicol
Macrolides and lincosamides
Erythromycin group and Clindamycin
Oxazolidinones/linezolide (Zyvox®)
Ketolides
Quinupristin-dalfopristin
Antimicrobial drugs
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V. Folic acid synthesis inhibitionSulphonamides, trimethoprim
VI. Complex mode of action
Glycopeptides(Vancomycin, Teicoplanin)
1. Cell wall2. Permeability (cell wall - membrane)3. DNA synthesis
Antimicrobial drugs
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I. Cell wall synthesis inhibition
Beta lactam drugs
1. penicillines
2. cephalosporines
3. others
(monobactam, carbapenem)
II. Cell membrane
destructionPolymyxin-B and - M
III. Nucleic acid level1. Quinolons, fluoroquinolons (gyrase inhibitors)
2. metronidazole = Klion®
(DNA damage by toxic metabolites) www.med.sc.edu:85
Antimicrobial drugs
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www.med.sc.edu:85
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www.med.sc.edu:85
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http://student.ccbcmd.edu/courses/b
io141/lecguide/unit2/control/penres_
fl.html
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I. Cell wall synthesis inhibitionBeta lactam drugs
1. penicillines
2. cephalosporines
3. others
(monobactam, carbapenem)
II. Cell membrane
destruction
Polymyxin-B and - M
III. Nucleic acid level1. Quinolons, fluoroquinolons (gyrase inhibitors)
2. metronidazole = Klion®
(DNA damage by toxic metabolites) www.med.sc.edu:85
Antimicrobial drugs
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www.med.sc.edu:85
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Antimicrobial drugs
I. Cell wall synthesis inhibitionBeta lactam drugs
1. penicillines
2. cephalosporines
3. others
(monobactam, carbapenem)
II. Cell membrane
destructionPolymyxin-B and - M
III. Nucleic acid level1. Quinolons, fluoroquinolons (gyrase inhibitors)
2. metronidazole = Klion®
(DNA damage by toxic metabolites) www.med.sc.edu:85
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www.idinchildren.com
Fluoroquinolones – mode of action
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Antimicrobial drugs
I. Cell wall synthesis inhibitionBeta lactam drugs
1. penicillines
2. cephalosporines
3. others
(monobactam, carbapenem)
II. Cell membrane
destructionPolymyxin-B and - M
III. Nucleic acid level1. Quinolons, fluoroquinolons (gyrase inhibitors)
2. metronidazole = Klion®
(DNA damage by toxic metabolites) www.med.sc.edu:85
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www.crsq.org
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Metronidazole – mode of action
TOXIC
Medmicro ch. 11
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IV. Protein synthesis inhibition- 30s ribosome subunit
Tetracyclines
Aminoglycosides
- 50s ribosome subunit
chloramphenicol
Macrolides and lincosamides
Erythromycin group and Clindamycin
Oxazolidinones/linezolide (Zyvox®)
Ketolides
Quinupristin-dalfopristin
Antimicrobial drugs
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www.scq.ubc.ca/.../2006/08/protein-
synthesis.gif
Protein synthesis
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IV. Protein synthesis inhibition- 30s ribosome subunit
Tetracyclines
Aminoglycosides
- 50s ribosome subunit
chloramphenicol
Macrolides and lincosamides
Erythromycin group and Clindamycin
Oxazolidinones/linezolide (Zyvox®)
Ketolides
Quinupristin-dalfopristin
Antimicrobial drugs
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www.med.sc.edu:85
Initiation of protein synthesis and antibiotics that inhibit initiation
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IV. Protein synthesis inhibition- 30s ribosome subunit
Tetracyclines
Aminoglycosides
- 50s ribosome subunit
chloramphenicol
Macrolides and lincosamides
Erythromycin group and Clindamycin
Streptogramins
Oxazolidinones/linezolide (Zyvox®)
Ketolides, Quinupristin-dalfopristin
Antimicrobial drugs
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www.med.sc.edu:85
Elongation of proteins and antibiotics that inhibit elongation
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IV. Protein synthesis inhibition- 30s ribosome subunit
Tetracyclines
Aminoglycosides
- 50s ribosome subunit
chloramphenicol
Macrolides and lincosamides
Erythromycin group and Clindamycin
Streptogramins
Oxazolidinones/linezolide (Zyvox®)
Antimicrobial drugs
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www.chm.bris.ac.uk/motm/linezolid/30s.gif
August 2005 Molecule of the Month
Linezolid
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Mode of action
www.chemsoc.org
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IV. Protein synthesis inhibition- 30s ribosome subunit
Tetracyclines
Aminoglycosides
- 50s ribosome subunit
chloramphenicol
Macrolides and lincosamides
Erythromycin group and Clindamycin
Streptogramins
Oxazolidinones/linezolide (Zyvox®)
Ketolides, Quinupristin-dalfopristin
Antimicrobial drugs
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Comparison of antibiotic binding sites. (A)
(B) Overview of the binding sites of quinupristin and dalfopristin within the 50S ribosomal subunit, in relation to the P-site tRNA and the ribosomal exit tunnel (highlighted in gold). www.biomedcentral.com
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V. Folic acid synthesis inhibition
Sulphonamides, trimethoprim
VI. Complex mode of actionGlycopeptides
(Vancomycin, Teicoplanin)
1. Cell wall2. Permeability (cell wall - membrane)3. DNA synthesis
Antimicrobial drugs
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www.med.sc.edu:85
Synthesis of tetrahydrofolic acid and antibiotics that inhibit
its synthesis
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V. Folic acid synthesis inhibitionSulphonamides, trimethoprim
VI. Complex mode of action
Glycopeptides(Vancomycin, Teicoplanin)
1.Cell wall2.Permeability (cell wall - membrane)3.DNA synthesis
Antimicrobial drugs
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Vancomycin – 3D
structure
www.ioc.uni-karlsruhe.de
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www.americanchemistry.com
www-personal.umich.edu/
chlorine-containing antibiotic
produced by the soil bacteria, Streptomyces orientalis
chemical formula,
C66H75Cl2N9O2,
shows that it is a
large molecule
"antibiotic of last-resort,"
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www.vhcy.gov.tw
www.appdrugs.com/ProdJPGs/VancomycinLg.jpg
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www.dundee.ac.uk
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http://images.google.hu/imgres?imgurl=http://s
tudent.ccbcmd.edu/courses/bio141/lecguide/u
nit2/control/images/vanresanim.gif&imgrefurl=
http://student.ccbcmd.edu/courses/bio141/lecg
uide/unit2/control/vanres.html&h=278&w=345
&sz=1168&hl=hu&start=108&tbnid=4mNyyhrQ
pMwttM:&tbnh=97&tbnw=120&prev=/images%
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http://student.ccbcmd.edu/courses/bio14
1/lecguide/unit2/control/vanres.html
student.ccbcmd.edu/.../images/vanresanim.gif
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stu
dent.ccbcm
d.e
du
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Antibiotic combinations
Antagonism
A + B = kill each other
Synergism
A + B = D, where D C
Additive
A + B = C,
where C = A + B
Neutral
A + B = A and B
AIMS1. Broaden the spectrum
2. Prevent and/or delay the resistance to develop
3. synergism
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Side effectsallergy
- penicillin
dysbacteriosis
candidiasis
Normal flora damage - broad spectrum drugs
direct toxic damage
- aminoglycosides (kidney)
- chloramphenicole (bone marrow)
- tetracyclines (teeth)
- Vancomycin (kidney, „ears”)
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Resistance
GENETIC BACKGROUND OF RESISTANCE:
- mutation (chromosome)
- plasmid coded “R” genes
usually both
Tools
Enzymes producedBinding receptor modificationPermeability Efflux pump (active)
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Resistance to…
1. Beta lactam drugs2. Macrolides and lincosamides
3. Chloramphenicole = Chlorocid
4. Tetracyclines
5. Aminoglycosides
6. Fluoroquinolones7. Sulfonamides
8. Metronidazole
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1.Beta lactam drugs- inhibit the peptidoglycan transpeptidation
Both chromosomal and plasmidbeta lactamase enzyme hydrolysis (beta lactam ring breaks )
trapping beta lactamase + cephalosporin = irreversible complex
amidase and acylase enzymes
altered structure of PBP (penicillin binding protein)
permeability
Resistance to…
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beta lactamase enzyme hydrolysis (beta
lactam ring breaks )
www.isrvma.org
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permeability enzyme!
www.med.sc.edu:85
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www.med.sc.edu:85
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Beta lactam antibiotics
Beta lactamase enzyme
Beta - Lactamase Inhibitors
Clavulanic acid Sulbactam TazobactamIn combination with beta lactam drugs
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www.isrvma.org
www.javeriana.edu.co
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TEM1 beta-lactamase structure
www.antibioresistance.be
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ww
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if
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2. Macrolides and lincosamides et.al
-Alteration of rRNA receptor by methylation
-Efflux
(ketolide)
www.princetoncme.com
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3. Chloramphenicol = Chlorocid
enzymatic inactivation
4. Tetracyclines
Permeability
-Ribosome-tRNA stabilisation no inhibition
of protein synthesis
5. Aminoglycosides
- plasmid adenylase, phosphorilase,
acetylase enzymes
inactivation and/or structural changes
Resistance to…
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6. Fluoroquinolones- DNA gyrase subunit A change /enzyme mutation/ no
binding
- Permeability- Efflux
www.facm.ucl.ac.be
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www.idinchildren.com
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7. Sulfonamides- higher affinity to PABA
(enzyme)
- more PABA produced
(mutation)
- inactivation by acetyl-
transferase (plasmid)
8. Metronidazolerarely seen
Resistance to…
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AntibioticYear
marketed
Year Resistance
first observed
Sulfonamides 1930 1940
Penicillin 1943 1946
Streptomycin 1943 1959
Chloramphenicol 1947 1959
Tetracycline 1948 1959
Erythromycin 1952 1988
Methicillin 1960 1961
Ampicillin 1961 1973
Cephalosporins 1960s late 1960sPalumbi, S.R. 2001.
Humans as the World's Greatest Evolutionary Force.
Science 293: 1786-1790. www.geo.arizona.edu
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www.geo.arizona.edu
Anti-staphylococcal drugs
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www.3db.co.uk/media/showcase/cubicin/cubicin2.jpg
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www.3db.co.uk/media/showcase/cubicin/cubicin2.jpg
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www.chem.ubc.ca/.../faculty/scotty/dapto.jpg
Daptomycin
Mode of action:
Cell membrane
depolarisation and
subsequent
inhibition of DNA,
RNA and protein
metabolism
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Gram-positive skin infections can now be treated with Cubicin (daptomycin), which is the first of a new class of antibiotics to be approved by the FDA in over two decades.Cubist Pharmaceuticals
www.nature.com/.../v21/n11/images/nbt904-I1.jpg
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COSTS OF HUMAN-INDUCED EVOLUTION
IN SOME INSECT PESTS AND DISEASES
Disease/Pest Cost per year
Additional pesticide application $1,200,000,000
Loss of crops $2 - 7,000,000,000
S. aureus Penicillin-resistant $ 2 - 7,000,000,000
S. aureus Methicillin-resistant $ 8,000,000,000
Community-acquired resistant $14 - 21,000,000,000
HIV drug resistance $ 6,300,000,000
Total for these factors $ 33 - 50,000,000,000
Stephen R. Palumbi. 2001. Humans as the world's greatest
evolutionary force. Science 293: 1786-1790. www.geo.arizona.edu
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THE END
Photo: istvan-istvan
Tele
nd
os,
2005