🦠Microbiology Unit 14 – Antimicrobial Drugs

What's This Unit About?

• Explores the world of antimicrobial drugs, their mechanisms of action, and their role in treating infectious diseases
• Covers the different classes of antimicrobials, including antibiotics, antifungals, antivirals, and antiparasitics
• Examines the spectrum of activity for various antimicrobial agents and their effectiveness against specific microorganisms
• Discusses the development of antimicrobial resistance and its impact on public health
• Delves into the clinical applications of antimicrobial drugs, including their use in prophylaxis and treatment of infections
• Highlights the importance of proper antimicrobial stewardship to minimize the emergence and spread of resistant strains
• Explores current research efforts aimed at discovering new antimicrobial agents and alternative therapies to combat resistant pathogens

Key Concepts and Definitions

• Antimicrobial drugs: substances that kill or inhibit the growth of microorganisms, including bacteria, fungi, viruses, and parasites
• Antibiotics: a subset of antimicrobial drugs that specifically target bacteria
  • Bactericidal antibiotics: kill bacteria directly (penicillins, cephalosporins, aminoglycosides)
  • Bacteriostatic antibiotics: inhibit bacterial growth and reproduction (tetracyclines, macrolides, sulfonamides)
• Antifungals: drugs that target fungal pathogens (azoles, polyenes, echinocandins)
• Antivirals: drugs that inhibit viral replication or block viral entry into host cells (nucleoside analogs, protease inhibitors, entry inhibitors)
• Antiparasitics: drugs that target parasitic infections (antiprotozoals, anthelmintics)
• Minimum Inhibitory Concentration (MIC): the lowest concentration of an antimicrobial agent that prevents visible growth of a microorganism
• Antimicrobial resistance: the ability of microorganisms to withstand the effects of antimicrobial drugs that were once effective against them

Types of Antimicrobial Drugs

• Antibiotics: further classified based on their chemical structure and mechanism of action
  • Beta-lactams: inhibit cell wall synthesis (penicillins, cephalosporins, carbapenems, monobactams)
  • Aminoglycosides: inhibit protein synthesis by binding to the 30S ribosomal subunit (gentamicin, tobramycin, amikacin)
  • Tetracyclines: inhibit protein synthesis by binding to the 30S ribosomal subunit (doxycycline, minocycline)
  • Macrolides: inhibit protein synthesis by binding to the 50S ribosomal subunit (erythromycin, clarithromycin, azithromycin)
  • Quinolones: inhibit DNA replication by targeting DNA gyrase and topoisomerase IV (ciprofloxacin, levofloxacin, moxifloxacin)
• Antifungals: target specific components of fungal cells
  • Azoles: inhibit ergosterol synthesis (fluconazole, itraconazole, voriconazole)
  • Polyenes: bind to ergosterol and disrupt fungal cell membranes (amphotericin B, nystatin)
  • Echinocandins: inhibit the synthesis of fungal cell wall components (caspofungin, micafungin, anidulafungin)
• Antivirals: interfere with various stages of the viral life cycle
  • Nucleoside analogs: inhibit viral DNA or RNA synthesis (acyclovir, ganciclovir, zidovudine)
  • Protease inhibitors: block viral protein maturation (ritonavir, saquinavir, indinavir)
  • Entry inhibitors: prevent viral entry into host cells (maraviroc, enfuvirtide)
• Antiparasitics: target specific metabolic pathways or structures of parasites
  • Antiprotozoals: treat infections caused by protozoan parasites (metronidazole, chloroquine, atovaquone)
  • Anthelmintics: eliminate helminthic infections (albendazole, mebendazole, praziquantel)

How Antimicrobials Work

• Antimicrobials target essential processes or structures in microorganisms, leading to their death or growth inhibition
• Cell wall synthesis inhibitors: interfere with the synthesis of peptidoglycan, a critical component of bacterial cell walls
  • Beta-lactams (penicillins, cephalosporins) bind to and inactivate penicillin-binding proteins (PBPs), enzymes involved in cell wall synthesis
  • Vancomycin binds to the D-alanine-D-alanine residues of peptidoglycan precursors, preventing their incorporation into the growing cell wall
• Protein synthesis inhibitors: target bacterial ribosomes, interfering with the translation of mRNA into proteins
  • Aminoglycosides bind to the 30S ribosomal subunit, causing misreading of the genetic code and production of non-functional proteins
  • Tetracyclines block the binding of aminoacyl-tRNA to the ribosome, preventing the addition of new amino acids to the growing polypeptide chain
  • Macrolides bind to the 50S ribosomal subunit, inhibiting the translocation of peptidyl-tRNA during protein synthesis
• Nucleic acid synthesis inhibitors: disrupt the replication or transcription of DNA or RNA
  • Quinolones inhibit DNA gyrase and topoisomerase IV, enzymes essential for DNA replication and supercoiling
  • Rifampin binds to bacterial RNA polymerase, preventing the initiation of RNA synthesis
• Metabolic pathway inhibitors: block essential metabolic processes in microorganisms
  • Sulfonamides and trimethoprim inhibit the folic acid synthesis pathway, which is crucial for nucleic acid synthesis and cell growth
  • Azoles inhibit the synthesis of ergosterol, a key component of fungal cell membranes
• Membrane disruptors: alter the permeability or integrity of microbial cell membranes
  • Polymyxins (colistin) bind to the lipopolysaccharide (LPS) layer of gram-negative bacteria, disrupting the outer membrane and increasing permeability
  • Polyenes (amphotericin B) bind to ergosterol in fungal cell membranes, creating pores that lead to the leakage of cellular contents

Spectrum of Activity

• Narrow-spectrum antimicrobials: effective against a limited range of microorganisms
  • Penicillin G is primarily active against gram-positive bacteria and some gram-negative cocci
  • Clindamycin is effective against anaerobic bacteria and some gram-positive cocci
• Broad-spectrum antimicrobials: active against a wide range of microorganisms, including both gram-positive and gram-negative bacteria
  • Tetracyclines have a broad spectrum of activity, covering gram-positive and gram-negative bacteria, as well as some intracellular pathogens (Chlamydia, Rickettsia)
  • Fluoroquinolones (ciprofloxacin, levofloxacin) are effective against a variety of gram-positive and gram-negative bacteria, including Pseudomonas aeruginosa
• Extended-spectrum antimicrobials: designed to cover a wider range of pathogens, particularly those resistant to other drugs
  • Extended-spectrum beta-lactamases (ESBLs) are enzymes produced by some gram-negative bacteria that confer resistance to many beta-lactam antibiotics
  • Carbapenems (imipenem, meropenem) have an extended spectrum of activity and are often used to treat infections caused by ESBL-producing bacteria
• Spectrum of activity is an important consideration when selecting an appropriate antimicrobial agent for empiric therapy, as it helps to ensure adequate coverage of the likely pathogens while minimizing the risk of promoting resistance

Resistance Mechanisms

• Antimicrobial resistance occurs when microorganisms develop the ability to survive and grow in the presence of drugs that were once effective against them
• Intrinsic resistance: inherent properties of a microorganism that render it naturally resistant to certain antimicrobials
  • Gram-negative bacteria are intrinsically resistant to vancomycin due to the impermeability of their outer membrane
  • Mycoplasma species lack a cell wall and are therefore resistant to cell wall synthesis inhibitors like beta-lactams
• Acquired resistance: develops through genetic changes or the acquisition of resistance genes from other microorganisms
  • Mutations in the target sites of antimicrobials can reduce their binding affinity and effectiveness (quinolone resistance due to mutations in DNA gyrase or topoisomerase IV)
  • Acquisition of resistance genes through horizontal gene transfer (plasmids, transposons, integrons) can confer resistance to multiple antimicrobials
• Resistance mechanisms can be classified into several categories:
  • Enzymatic inactivation: production of enzymes that degrade or modify antimicrobials (beta-lactamases, aminoglycoside-modifying enzymes)
  • Altered target sites: modifications in the structure of the antimicrobial target that reduce its binding affinity (penicillin-binding protein alterations in methicillin-resistant Staphylococcus aureus)
  • Reduced permeability: changes in the bacterial cell envelope that limit the entry of antimicrobials (porin mutations in gram-negative bacteria)
  • Efflux pumps: active transport systems that pump antimicrobials out of the cell, reducing their intracellular concentration (tetracycline efflux pumps)
• The emergence and spread of antimicrobial resistance pose significant challenges to the effective treatment of infectious diseases, highlighting the need for judicious use of antimicrobials and the development of new therapeutic strategies

Clinical Applications

• Empiric therapy: initiating antimicrobial treatment based on the suspected pathogen and site of infection, prior to the availability of culture and susceptibility results
  • Broad-spectrum antimicrobials are often used for empiric therapy to ensure adequate coverage of potential pathogens
  • Local epidemiology and resistance patterns should be considered when selecting empiric therapy
• Definitive therapy: tailoring antimicrobial treatment based on the identified pathogen and its susceptibility profile
  • Narrowing the spectrum of antimicrobial coverage once the causative organism is identified can help minimize the risk of resistance and adverse effects
  • Combination therapy may be used for synergistic effect or to prevent the emergence of resistance in certain situations (tuberculosis treatment)
• Prophylaxis: use of antimicrobials to prevent infections in high-risk situations
  • Surgical prophylaxis: administration of antimicrobials prior to surgical procedures to reduce the risk of postoperative infections
  • Chemoprophylaxis: long-term use of antimicrobials to prevent infections in immunocompromised patients or those with recurrent infections (HIV patients, sickle cell disease)
• Antimicrobial stewardship: coordinated interventions designed to improve and measure the appropriate use of antimicrobials
  • Goals include optimizing clinical outcomes, minimizing adverse effects, reducing costs, and limiting the emergence and spread of resistance
  • Strategies involve education, guidelines, formulary restrictions, prospective audit and feedback, and de-escalation of therapy when appropriate
• Therapeutic drug monitoring: measuring antimicrobial concentrations in the blood to ensure adequate levels are achieved and maintained
  • Important for drugs with narrow therapeutic indices or high interindividual variability (aminoglycosides, vancomycin)
  • Helps to optimize efficacy, minimize toxicity, and adjust dosing in patients with altered pharmacokinetics (renal impairment, obesity)

Side Effects and Considerations

• Antimicrobial agents can cause a range of adverse effects, some of which may be severe or life-threatening
• Allergic reactions: hypersensitivity responses to antimicrobials, ranging from mild rashes to anaphylaxis
  • Beta-lactam antibiotics (penicillins, cephalosporins) are among the most common causes of drug allergies
  • Cross-reactivity between different classes of beta-lactams should be considered when selecting alternative agents
• Gastrointestinal disturbances: nausea, vomiting, diarrhea, and abdominal pain are common side effects of many antimicrobials
  • Clostridium difficile infection is a serious complication associated with the use of broad-spectrum antibiotics, particularly clindamycin and fluoroquinolones
  • Probiotics may be used to restore the balance of gut microbiota and prevent antibiotic-associated diarrhea
• Nephrotoxicity: kidney damage can occur with certain antimicrobials, especially when used in high doses or in combination with other nephrotoxic agents
  • Aminoglycosides and vancomycin are known to cause acute kidney injury, particularly in patients with pre-existing renal impairment
  • Monitoring renal function and adjusting doses based on creatinine clearance can help minimize the risk of nephrotoxicity
• Hepatotoxicity: liver injury is a potential complication of some antimicrobials, particularly those metabolized by the liver
  • Isoniazid, rifampin, and ketoconazole are associated with a higher risk of hepatotoxicity
  • Monitoring liver function tests and discontinuing therapy if signs of liver injury develop are important safety measures
• Neurotoxicity: certain antimicrobials can cause central or peripheral nervous system adverse effects
  • Ototoxicity (hearing loss) and vestibular toxicity are well-known side effects of aminoglycosides, especially with prolonged use or high serum concentrations
  • Fluoroquinolones have been associated with peripheral neuropathy, tendinopathy, and rarely, central nervous system effects (seizures, psychosis)
• Drug interactions: antimicrobials can interact with other medications, leading to altered pharmacokinetics or pharmacodynamics
  • Macrolides and azole antifungals are potent inhibitors of cytochrome P450 enzymes, which can increase the levels of other drugs metabolized by these enzymes (statins, warfarin)
  • Careful review of concomitant medications and dose adjustments may be necessary to avoid potential drug interactions

Current Research and Future Directions

• The increasing prevalence of antimicrobial resistance has spurred research into new therapeutic strategies and alternative approaches to combat resistant pathogens
• Novel antimicrobial agents: development of new classes of antimicrobials with unique mechanisms of action
  • Teixobactin is a recently discovered antibiotic that targets lipid II and lipid III, essential components of bacterial cell wall synthesis, and shows activity against resistant gram-positive bacteria
  • Murepavadin is a novel antibiotic that selectively targets the outer membrane protein LptD in Pseudomonas aeruginosa, disrupting lipopolysaccharide transport and cell envelope integrity
• Combination therapy: using multiple antimicrobials with different mechanisms of action to enhance efficacy and reduce the risk of resistance
  • Ceftazidime-avibactam is a combination of a third-generation cephalosporin and a novel beta-lactamase inhibitor, designed to treat infections caused by carbapenem-resistant Enterobacteriaceae
  • Imipenem-relebactam is another beta-lactam/beta-lactamase inhibitor combination that shows activity against carbapenem-resistant gram-negative bacteria
• Antimicrobial peptides: naturally occurring or synthetic peptides that exhibit broad-spectrum antimicrobial activity and low potential for resistance development
  • Defensins and cathelicidins are endogenous antimicrobial peptides produced by the innate immune system, with potential therapeutic applications
  • Engineered cationic antimicrobial peptides (eCAPs) are synthetic peptides designed to optimize antimicrobial activity and minimize toxicity to host cells
• Phage therapy: using bacteriophages (viruses that infect bacteria) to selectively target and kill pathogenic bacteria
  • Phage cocktails containing multiple phages with different host ranges can be used to treat infections caused by resistant bacteria
  • Genetically engineered phages expressing antimicrobial peptides or biofilm-degrading enzymes are being explored to enhance their therapeutic potential
• Microbiome modulation: manipulating the human microbiome