BASIC PRINCIPLES OF CHEMOTHERAPEUTIC AGENTS

Chemotherapy
Chemotherapy: chemo + therapy The use of drug (chemical entity/ substance derived form microorganisms) with selective toxicity against infections/viruses, bacteria, protozoa, fungi and helminthes is called as chemotherapy.

Antibiotics and Antimicrobials

Antibiotics: Antibiotics are substances produced by
microorganisms, which selectively suppress the growth of or kill other microorganisms at very low concentration.

Antimicrobials: (chemotherapeutic agent + Antibiotics)

Any substance of natural, synthetic or semisynthetic origin which at low concentrations kill or inhibits the growth of microorganisms but causes little or no host damage.

History of chemotherapy

History of chemotherapy Before Ehrlichs period (till 1900) Chaulmoogra oil by Hindus in leprosy Cinchona bark for fever Mouldy curd by chines on boils Mercury by Paracelsus for syphilis Ehrlichs period (1900 to 1930) Organometallic dye for treatment for cane After Ehrlichs period (1930 to till date) discovery of sulfonamide (Prontosil)

Antimicrobial Drugs

Antimicrobial Drugs
Chemicals used to treat microbial infections Before antimicrobials, large number of people died from common illnesses Now many illnesses easily treated with antimicrobials However, many antimicrobial drugs are becoming less useful

Antimicrobial Drugs
Chemotherapeutic agent= Antimicrobial drug=

Different types of antimicrobial drugs:

Antibacterial drugs Antifungal drugs Antiprotozoan drugs Antihelminthic drugs

Principles of antimicrobial therapy

 Diagnosis: Site of infection, responsible organism, sensitivity of drug Decide- chemotherapy is necessary: Acute infection require chemotherapy whilst chronic infections may not. The chronic abscess respond poorly, although chemotherapy cover is essential if surgery is undertaken to avoid a flare-up of infection. Select the drug: Specificity (spectrum of activity, antimicrobial activity of drug), pharmacokinetic factors (physiochemical properties of the drug) , patient related factors (allergy, renal disease)

 Frequency and duration of drug administration: Inadequate dose may develop resistance, intermediate dose may not cure infection, optimize dose should be used for therapy. Continue therapy: Acute infection treated for 5-10 days. But some of the bacterial infection exceptions to this. E.g.: Typhoid fever, tuberculosis and infective endocarditis (after clinical cure, the therapy is continued to avoid relapse). Test for cure: After therapy, symptoms and signs may disappear before pathogen eradicated. Prophylactic chemotherapy: To avoid surgical site infections.

Features of Antimicrobial Drugs

1. 2. Most modern antibiotics come from species of microorganisms that live in the soil To commercially produce antibiotic: Select strain and grow in broth When maximum antibiotic concentration reached, extract from medium Purify Chemical alter to make it more stable

3. 4.

Features of Antimicrobial Drugs:

Selective Toxicity
Cause greater harm to microorganisms than to host Chemotherapeutic index: lowest dose toxic to patient divided by dose typically used for therapy

Features of Antimicrobial Drugs:

Antimicrobial Action
Bacteriostatic: inhibit growth of microorganisms Bactericidal: Kill microorganisms

Features of Antimicrobial Drugs:

Spectrum of Activity
Antimicrobial medications vary with respect to the range of microorganisms they kill or inhibit Some kill only limited range : Narrowspectrum antimicrobial While others kill wide range of microorganisms: Broad-spectrum antimicrobial

Features of Antimicrobial Drugs:

Effects of Combining Drugs

Combinations are sometimes used to fight infections Synergistic: action of one drug enhances the activity of another or vice versa. Antagonistic: activity of one drug interferes with the action of another.

Features of Antimicrobial Drugs:

Adverse Effects
1. Allergic Reactions: some people develop hypersensitivities to antimicrobials 2. Toxic Effects: some antimicrobials toxic at high concentrations or cause adverse effects 3. Suppression of normal flora: when normal flora killed, other pathogens may be able to grow to high numbers

Features of Antimicrobial Drugs:

Resistance to Antimicrobials
Some microorganisms inherently resistant to effects of a particular drug Other previously sensitive microorganisms can develop resistance through spontaneous mutations or acquisition of new genes (more later).

So, The Criteria of the Ideal Antibiotic:

Selectively toxic to microbe but nontoxic to host. Soluble in body- tissue distribution. Remains in body long enough to be effective resists excretion and breakdown. Shelf life. Does not lead to resistance. Cost not excessive. Hypoallergenic. Microbiocidal rather than microbiostatic. Concerns suppression of normal flora antibiotic associated colitis with Clostridium difficule and its toxins or Candida albicans.

Mechanisms of action of Antibacterial Drugs

1. 2. 3. 4. 5. Inhibit cell wall synthesis Inhibit protein synthesis Inhibit nucleic acid synthesis Injury to plasma membrane Inhibit synthesis of essential metabolites

Figure 20.2

Inhibition of Cell Wall Synthesis: b-Lactam Drugs

Irreversibly inhibit enzymes involved in the final steps of cell wall synthesis These enzymes mediate formation of peptide bridges between adjacent stands of peptidoglycan b-lactam ring similar in structure to normal substrate of enzyme Drug binds to enzyme, competitively inhibit enzymatic activity

b-Lactam Drugs
Some bacteria produce b-lactamaseenzyme that breaks the critical b-lactam ring b-lactam drugs include: penicillins and cephalosporins

Penicillins (Benzylpenicillin)
Acid-labile. Gram+ bacteria. So, take phenoxymethylpenicillin. Large Vd, but penetration into brain: poor, except when the meninges are inflammed. Broad spectrum penicillins: amoxicillin and ampicillin are more hydrophillic and therefore, are active against grambacteria.

Penicillins (Benzylpenicillin)
Penicillinase-resistant penicillins Flucloxacillin Indicated in infections caused by penicillinaseproducing pen-resistant staphlococci. Has an isoxazolyl group at R1 sterically hinders access of the enzyme to the -lactam ring. Less effective than benzylpen. So, should be used only for pen-resistant infections. Well-absorbed orally, but in severe infections, should be i.v. and not alone. Staphlococci aureas-resistant strains to flucloxicillin and MRSA (methicillin-resistant Staph aureas) increasing problem.

Broad-Spectrum Penicillins
Ampicillin and amoxicillin very active against non-lactamase-producing gram+ bacteria. Because they diffuse readily into Gram- bacteria, also very active against many strains of E. coli, H. influenzae, and Salmonella typhimurium. Orally, amoxicillin is better because absorption is better. Ineffective against penicillinase-producing bacteria (e.g., S. aureus, 50% of E. coli strains, and up to 15 % of H. influenzae strains. Many baterial -lactamases are inhibited by clavulaic acid amoxicillin (co-amoxiclav) antibiotic is effective against penicillinase-producing organisms. Co-amoxiclav indicated in resp and UT infections, which are confirmed to be resistant to amoxicillin.

Cephalosporins
Used for treatment of meningitis, pneumonia, and septicemia. Same mech and pcol as that of pens. May allergic rxn and cross-reactivity to pen. Similar to pens in broad-spectrum antibacterial activity. Cedadroxil (for UTI) in case of antibact resist. Cefuroxime (prophylactic in surgery) Resistant to inactivation by -lactamases and used in severe infections (others ineffective). Ceftazidine wide range of activity against gram- including Pseudomonas aeruginosa), but is less active than cefurozime against gram+ bact (S aureus). Used in meningitis (CNS-accessible) caused by grambacteria.

Vancomycin
Not well absorbed orally. Inhibits peptidoglycan formation. Active against most gram+ organisms. I.v. treatment for septicemia or endocarditis caused by MRSA. Used for pseudomembranous colitis (superinfection of the bowel by Clostridium difficile produces a toxin that damages the colon mucosa)

Antibacterial Drugs that Inhibit Cell Wall Synthesis

Antibacterial Medications that Inhibit Protein Synthesis

Target ribosomes of bacteria Aminoglycosides: bind to 30S subunit causing it to distort and malfunction; blocks initiation of translation Tetracyclines: bind to 30S subunit blocking attachment of tRNA. Macrolides: bind 50S subunit and prevents protein synthesis from continuing.

Aminoglycosides Against many gram- and some gram+. Narrow TI very potentially toxic. Most important adverse side-effect: VIIIth cranial n. (ototoxicity) and kidney damage. Resistance several mechs: inactivation of the drug by acetylation, phos, or adenylation, envellope to prevent drug access, and the binding site of the 30S subunit (streptomycin only).

Aminoglycosides
Gentamicin used for acute, life-thretening graminfections. Has synergism with pen and van and combo. Amikacin used for bact that are gent-resistant. Netilmicin less toxic than gentamicin. Neomycin too toxic for parenteral use. Used for topically for skin infections and orally for sterilizing bowel before surgery. Streptomycin active against Mycobacterium tuberculosis. But bec of its ototoxicity, rifampicin replaces. Rifampicin resistance develops quickly alone; so, with TB, combine with isoniazid, ethambutol, and pyrazinamide for the 1st 2 mos of treatment, followed by another 4 mos with rifampicin and isoniazid.

Macrolides
Very safe drugs. Ususally given orally. Erythromycin and clarithomycin Effective against gram- bact and can be used as an alt to pen-sensitive patients, esp in infections caused by streptococci, staphylococci, pneumococci, and clostridia. Dont cross the BBB ineffective against meningitis. Resistance- occurs bec of plasmid-controlled of their receptor on the 50S subunit. Erythromycin in high doses, may cause nausea and vomiting (less so with clarithromycin and azithromycin). Azithromycin very long t1/2 (~40-60 hr) and a single dose is as effective in treating chlamydial non-specific urethritis as tretracycline admin over 7 days,

Tetracyclines
Broad-spectrum. Penetrate microorganisms well. Sensitive organisms accumulate it through partly passive diffusion and partly through active transport. Resistant organisms develop an efflux pump and do not accumulate the drug. Genes for tet-resistance transmitted by plasmids. Closely assoc with those for other drugs to which the organisms will also be resistant (e.g., sulphonamides, aminoglycosides, chloramphenicol). Tets bind to Ca in growing bones and teeth can discolor teeth. So, should be avoided in children < 8 yrs old.

Chloramphenicol
Broad-spectrum. Serious side-effects: bone marrow aplasia, suppression of RBCs, WBCs, encephalopathy, optic neuritis. So, periodic blood counts required, esp in high doses. Large Vd, including CNS. Inhibits the actions of other drugs and may incr the actions of phenytoin, sulphonlureas, and warfarin. Neonates cannot met the drug rapidly accum grey baby syndrome (pallor, abdominal distension, vomiting, and collapse).

Antibacterial Drugs that Inhibit Protein Synthesis

Antibacterial Medications that Inhibit Nucleic Acid Synthesis

Target enzymes required for nucleic acid synthesis Fluoroquinolones: inhibit enzymes that maintain the supercoiling of closed circular DNA Rifamycins: block prokaryotic DNAdependent RNA polymerase from initiating transcription

Sulphonamides
Sulfadiazine well-absorbed orally. Used to treat UTIs. But many strains of E. coli are resistant. So, use less toxic drugs instead. Adverse effects: allergic rxns, skin rashes, fever. Trimethoprin used for UTIs and Resp TIs Co-trimoxazole (trimethoprin + sulfamethoxazole) used mostly for pneumonia, neocarditis, and toxoplasmosis.

Antibacterials Competitive Inhibitors

Sulfonamides (Sulfa drugs)
Inhibit folic acid synthesis Broad spectrum

Figure 5.7

Figure 20.13

Quinolones (GABA antagonists)

Inhibit DNA gyrase. Nalidixic acid used only for UTIs. Ciprofloxin (6-fluoro substituent) that greatly enhances its effectiveness against both gramand gram+ bacteria. Well-absorbed both orally and i.v. Eliminated largely unchanged by the kidneys. Side-effects (headache, vomiting, nausea) are rare; but convulsions may occur.

5-Nitroimidazoles
Wide-spectrum Metronidazole against anaerobic bacteria and protozoan infections. Tinidazole longer duration of action. Diffuses into the organism where the nitro group is reduced chemically reactive intermediates are formed that inhibit DNA synthesis and/or damage DNA.

Antibacterial Drugs that Inhibit Nucleic Acids

Antibacterial medications that Injure Plasma Membrane

Polymyxin B: binds to membrane of Gbacteria and alters permeability This leads to leakage of cellular contents and cell death These drugs also bind to eukaryotic cells to some extent, which limits their use to topical applications

Antibacterial Drugs that Inhibit Synthesis of Essential Metabolites

Competitive inhibition by substance that resembles normal substrate of enzyme Sulfa drugs

Antiviral Drugs
Very few antiviral drugs approved for use in US Effective against a very limited group of diseases Targets for antiviral drugs are various points of viral reproduction

Drugs that Prevent the Virus from Entering or Leaving the Host Cells
Amantadine interferes with replication of influenza A by inhibiting the transmembrane M2 protein that is essential for uncoating the virus. - Has a narrow spectrum; so, flu vaccine is usually preferable. Zanamivir inhibits both influenza A and B neuraminadase. Decr duration of symptoms if given within 48 hr of the onset of symptoms. Prophylactic in healthy adults. Immunoglobulins Human Ig contains specific Abs against superficial Ags of viruses can interfere with their entry into host cells. Protection against hepA, measles, and rubellla (German measles).

Drugs that Inhibit Nucleic Acid Synthesis Nucleoside and Nucleotide Analogs
Acyclovir- used to treat genital herpes Cidofovir- used for treatment of cytomegaloviral infections of the eye Lamivudine- used to treat Hepatitis B

Acyclovir
HSV and VZV contain a thymidine kinase (TK) that acyclovir to a monophosphate phosphorylated by host cell enzymes to acycloguanosine triphosphate, which inhibits viral DNA pol and viral DNA synthesis. Selectively toxic (TK of uninfected host cells activates only a little of the drug). Viral enzymes have a much higher affinity than the host enzymes for the drug. Effective against HSV, but does not eradicate them. Need high doses to treat shingles.

Ganciclovir
Quite toxic (neutropenia) so, given only for severe CMV infections in immunosuppressed patients. CMV is resistant to acyclovir because it does not code for TK.

 Currently implies a drug used to treat HIV Tenofovir- nucleotide reverse transcriptase inhibitor Zidovudine- nucleoside analog inhibits RT of HIV and is only used orally for AIDS. - Activated by triple phosphorylation and then binds RT (with100X affinity than for cellular DNA pols). - Incorporated into the DNA chain, but lacks a 3OH; so another nucleoside cannot form a 3-5-phosphodiester bond DNA chain elongation is terminated. -Severe adverse effects: anemia, neutropenia, myalgia, nausea, and headaches. Stavudine, didanosine, zalcitabine among other NRTIs. Nevirapine, efavirenz Non nucleoside RTIs - denature RT.

Antiretrovirals

Life Cycle of HIV

HIV gp41-mediated fusion and enfuvirtide (T-20) action Prohibits HIV entry

Other enzyme inhibitors

Zanamivir (Relenza) and Oseltamivir phosphate (Tamiflu)- inhibitors of the enzyme neuominidase
Used to treat influenza

Indinavir- protease inhibitors. Inhibit the synthesis of essential viral proteins (e.g., RT) by viral-specific proteases.

Interferons
Cells infected by a virus often produce interferon, which inhibits further spread of the infection Alpha-interferon - drug for treatment of viral hepatitis infections

Kirby-Bauer Method for Determining Drug Susceptibility

1. Bacteria spread on surface of agar plate 2. 12 disks, each with different antimicrobial drug, placed on agar plate 3. Incubated- drugs diffuse outward and kill susceptible bacteria 4. Zone of inhibition around each disk 5. Compare size of zone to chart

Figure 21.10

Resistance to Antimicrobial Drugs

Drug resistance limits use of ALL known antimicrobials Penicillin G: first introduced, only 3% of bacteria resistant Now, over 90% are resistant

Mechanisms Responsible for Resistance to Antimicrobial Drugs Include the Following:

1. Inactivating enzymes that destroy the drug (e.g., -lactamases). 2. Decreased drug accumulation (e.g., tet). 3. Altering the binding sites (e.g., aminoglycosides and erythromycin). 4. Development of alternative metabolic pathways (sulphonamides ( dihydropteroate synthease) and trimethoprim (dihydrofolate reductase).

How do Bacteria Become Resistant?

1. Spontaneous Mutation: happen as cells replicate Within a pop, there will be some bact with acquired resistance. The drug then elim the sensitive organisms, while the resistant ones proliferate. 2. Gene Transfer or Transferred resistance: Usually spread through conjugative transfer of R plasmid ( may be virally mediated).

Slowing the Emergence and Spread of Antimicrobial Resistance

1. Responsibilities of Physicians: must work to identify microbe and prescribe suitable antimicrobials, must educate patients 2. Responsibilities of Patients: need to carefully follow instructions

Slowing the emergence and spread of antimicrobial resistance

3. Educate Public: must understand appropriateness and limitations of antibiotics; antibiotics not effective against viruses 4. Global Impacts: organism that is resistant can quickly travel to another country - in some countries antibiotics available on non-prescription basis - antibiotics fed to animals can select for drug- resistant organisms

New Approaches to Antibiotic Therapy Are Needed

Scientists work to find new antibiotic targets in pathogens Discovery of new and unique antibiotics is necessary