4/14/2019

Antibiotics
David A. Baker
Office 429B
Phone 8-6634 or 8-6635
Email david.baker@marquette.edu

Things bacteria can do

• Make it rain: Bioprecipitation – precipitation dependent
upon airborne microbes. Before a cloud can produce rain or
snow, rain drops or ice particles must form. This requires
the presence of aerosols: tiny particles that serve as the
nuclei for condensation. Airborne microbes — bacteria,
fungi or tiny algae — can do the job.

• Live for millions of years: Bacillus cereus strain F has

recently been found, and appears to be over 2 million years
old. The bacteria has been injected into people in the
hopes that it is the key to human longevity

• Swim faster than Michael Phelps: Ovobacter propellens

moves at an astonishing rate that is equivalent to 200X its
body length/sec; Phelps swims at a pace of 1 body
length/sec

• Make gold: Cupriavidus metallidurans forms nanoscale gold

nuggets to help it to grow in toxic mine waste
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• Keep us alive

• Kill us

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Trivia Question:
What needs to be done to decrease the
mortality rates of cancer and heart
disease?

Answer:
Nothing, we just need to keep using
antibiotics as we have over the past 60+
years

• Prior to the Antibiotic Era:

o Life expectancy was 47 years
o The Top Four Causes of Death Involved
Infectious Disorders
• 1945-today: Penicillin alone has saved an estimated
200 million lives
• Modern day: Risk for a post-antibiotic era in which
infectious diseases become leading causes of
mortality due to widespread antibiotic resistance

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Potential End of the Antibiotic Era

• World Health Organization has warned that "many

common infections will no longer have a cure and,
once again, could kill unabated
• US Centers of Disease Control has pointed to the
emergence of "nightmare bacteria"
• Many basic operations - getting an appendix
removed or a hip replacement - could become
deadly
• Cancer treatments and organ transplants could kill
you. Childbirth could once again become a deadly
moment in a woman's life
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Some estimates are that global antibiotic resistance
crisis could kill 10 million people each year by 2050

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Addressing Antibiotic Resistance

Improved use of antibiotics
• Tougher restrictions/guidelines
o Up to 30% of antibiotic prescriptions in the US were unnecessary
o Many European countries permit access to antibiotics without a prescription
• Obtain adequate bacteriological information
• Use of proper dosage/duration/route of administration
• Increased number of scientific studies establishing best practices
o Many uses of antibiotics lack evidence-based guidelines in the use of antibiotics
• Restrict non-medicinal use of antibiotics

Develop alternatives to antibiotics

• Prevent infections using vaccines, probiotics, immunotherapies
• Treat infections with non-antibiotic approaches (e.g., control over predatory bacteria)
o Bdellovibrio bacteriovorus - attach to gram negative bacteria, establishes itself in the periplasm of cell, digesting the cell
from within
o Micavibrio aeruginosavorus - are ‘vampire-like’ bacteria that attach to a prey cell’s outer membrane from the outside and
leaches nutrients

Improved Development of Novel Classes

• Antibiotics have a poor return on investments
• Few if any new classes of antibiotics have been developed in the past few decades
o The main pathways and targets enabling broad-spectrum antibiotics have already been targeted
• Develop new ways to culture bacteria - iChip

iChip & the future of antibiotics

(fyi)
• 2015: a team of researchers from Northeastern University developed iChip
• The device solved the Great Plate Count Anomaly
o Great Plate Count Anomaly - refers to the limited number of bacterial colonies
found in environmental samples (e.g., soil) that can grow on an agar plate (petri
dish used to grow cultured microorganisms)

iChip
o electronic chip that can be used to culture microbes in the soil and isolate their
antibiotic chemical compounds
o Was used to discover Teixobactin, the first truly novel antibiotic in decades

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Consequence of Antibiotic Use

• Assist the host immune system in eradicating an infection
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Consequence of Antibiotic Use:

Assist the host immune system in eradicating an infection

• Bacteriostatic versus bactericidal

Static Agents -
Cidal Agents -

Factors Determining Cidal Activity

- mechanism of action
- drug concentration
- site of infection
- microbial pathogen

Cidal agents are commonly preferred for

serious infections because there is less
dependence on host immune system

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Consequence of Antibiotic Use:

Assist the host immune system in eradicating an infection

• Bacteriostatic versus bactericidal

• Selective Toxicity

Dosing Parameters
• Concentration-Dependent Drugs
• Time-Dependent Drugs

Spectrum of Activity
• Broad spectrum versus narrow spectrum
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Which of the above attributes is a function
of a drug’s MOA? MBC: Minimum bactericidal concentration

Can an antibiotic fully eradicate a bacterial How would you dose a concentration-
infection? dependent drug? A time-dependent drug?

Gram Stain and Spectrum of Activity

Gram + Gram -

The gram stain reveals key morphological differences in bacteria that can determine
susceptibility and resistance to individual antibiotics:
• Cell wall (peptidoglycan) thickness
• Outer membrane
• Porins

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Assist the host immune system in eradicating an infection

Types of Antibiotic Therapy

• Empirical
• Definitive
• Prophylactic
o Principles of antibiotic prophylaxis:
• An antibiotic loading dose (2-4X the maintenance) must be used
• The antibiotic chosen should be active against the single most likely microbe.
• Use of the antibiotic is restricted to the likely duration of microbe exposure
• Population at risk can be defined
• Satisfactory cost-benefit ratio to ensure that the benefit to the patient significantly
outweighs medical and financial risks

Is empirical therapy more likely to involve the use of a

broad-spectrum or narrow-spectrum antibiotic?
What about definitive therapy?

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Consequence of Antibiotic Use

• Assist the host immune system in eradicating an infection
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• Promote drug-resistance among bacteria

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Drug-Induced Increases in Resistance

Natural Resistance
• Bacteria display a range in the degree of
susceptibility/resistance to a given drug
o Typically depicted as the concentration
of the drug needed to produce an effect
• Antibiotics can lead to an increase in surviving
bacteria that display natural resistance

Acquired Resistance
Highly Susceptible
• Involves bacteria acquiring the genes that enable
inherent resistance Intermediate Resistance
• Exposure to antibiotics can trigger the mechanisms
High-level Resistance
whereby highly-resistant bacteria share genetic
material

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Drug-Induced Increases in Natural Resistance

Antibiotics can select for bacteria that
display high levels of resistance to a drug
(and often to other drugs with similar
mechanisms of action)
Susceptible
Intermediate
High-level resistance

PRE: Antibiotic Treatment Bacteria surviving the antibiotic

X X X X
X X

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Drug-Induced Increases in Acquired Resistance

Antibiotics stimulate bacteria to share the
genetic material conferring antibiotic
resistance.
Susceptible
Intermediate
High-level resistance

PRE: Antibiotic Treatment Bacteria surviving the antibiotic

X X X X
X X

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Consequence of Antibiotic Use

• Assist the host immune system in eradicating an infection
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• Promote drug-resistance among bacteria

• Adverse Reaction
• Selective Toxicity

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Selective Toxicity
• Means by which a drug selectively or preferentially
impacts bacterial cells relative to eukaryotic host cells
• In practice, this is expressed as a drug’s therapeutic
index (ratio of the toxic and therapeutic doses)
• Several hundreds of compounds with antibiotic
activity have been isolated from microorganisms over
the years, but only a few of them are clinically-useful
• Selective toxicity occurs when:
o A drug targets a process vital to bacteria that
does not exist in eukaryotic cells
• Blockade of cell wall synthesis, repair
o A drug preferentially impairs a process vital to
bacteria in a manner that minimally impacts a
similar process in eukaryotic cells
o Use of inhibitors that are selective for
dihydrofolate reductase expressed by
bacteria rather than eukaryotic cells

Trimethoprim inhibits dihydrofolate reductase;

bacterial dihydrofolate reductase has a much
higher (40,000X) affinity for trimethoprim than
human dihdrofolate reductase.

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Consequence of Antibiotic Use

• Assist the host immune system in eradicating an infection
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• Promote drug-resistance among bacteria

• Adverse Reaction
• Selective Toxicity
• Dysbiosis

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Human Microbiome
The human body relies on a complex ecosystem that includes
trillions of bacteria and other microorganisms that inhabit all
of our surfaces.

• 39 trillion microbes bacteria (which is comparable

to or greater than the number of human cells)

Human microbiome is essential for life

• Bacteria contribute to critical functions ranging

from absorption of nutrients to digestion to
immune responses
• Recent findings implicate bacteria as critical
determinants of the function and development of
other systems as well, including the CNS.

Human microbiome also has the potential to underlie a

broad array of diseases
• Focal Infection Theory of Disease

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Human microbiome project was launched in 2007 to analyze
its role in health and disease

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• The symbiotic relationship is likely much more broad than ever imagined
• The human microbiome is influenced by factors ranging from age to
exercise to stress
• By altering our microbiome, each of these factors has the potential to
promote or impair human health through microbe-mediated mechanisms

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Dysbiosis of the gut microbiota is associated with the pathogenesis of both intestinal and extra-
intestinal disorders
• Intestinal disorders include inflammatory bowel disease, irritable bowel syndrome (IBS), and
coeliac disease
• Extra-intestinal disorders include allergy, asthma, metabolic syndrome, cardiovascular disease, and
obesity

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Microbiome, Immune System, Disease

many diseases are impacted by the microbiome’s capacity to modulate the immune system,
specifically in its ability to influence levels of inflammation in the gut, as well as systemically

• PD-1 (programmed death-1) and PD-L1

(programmed death ligand-1) can collectively shield
cancer cells from components of the immune
system.
• Immunotherapy involving blocking PD-1 better
enabled the immune system to detect and eradicate
a tumor
• Anti–PD-1–based immunotherapy has had a major
impact on cancer treatment but has only benefited
a subset of patients
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• Recent work illustrates that the composition of the
microbiome may determine the clinical response by
influencing the immune system activation state
following PD-L1 blockade

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Control
Water PD1 Blockade
Control
Antibiotic PD1 Blockade

Antibiotics compromise the efficacy

of PD-1 blockade

Antibiotics oppose the therapeutic effects of

immunotherapy involving PD-1 blockade. This is
evident from an lack of an effect of PD-1
blockade on tumor size and overall survival

Bertrand Routy et al. Science 2018;359:91-97

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Dysbiosis (also called dysbacteriosis) - microbial

imbalance or maladaptation on or inside the body
A diverse and non-disturbed microbiota confers resistance to colonization by enteric
pathogens in the intestinal epithelium.

Treatment with antibiotics decreases the diversity of the microbiota and leads
to expansion of the C. difficile population. Toxins that are released from C.
difficile enter and damage the cells of the epithelium, which leads to
inflammation (colitis) and cell death

Antibiotics also lead to an increase in the release of host (sialic acid) and bacterial
factors (succinate) that further disturb the microbiota. For example, succinate can
trigger bacteria to produce an enzyme to degrade the mucus layers of the intestine,
enabling bacteria to attach and invade intestinal epithelium

Changes in the microbiota can confer resistance

to or promote infection by pathogenic bacteria

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Dysbiosis and Superinfections

Acute otitis media

new infection arising

during the chemotherapy
of the primary infection
Potential Bacterial Pathogens Antibiotic-induced
Typically caused by the diarrhea
Streptococcus pneumoniae (+)
removal of inhibitory
influence of preexisting Hemophilus influenzae (-)
flora

More common w/ broad

spectrum antibiotics and Empirical Therapy
combination therapy Amoxicillin PO

C difficile (gram +)
grows unchecked by
E coli
Disruption of E coli (gram
-) in the lower GI tract

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