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CELL WALL INHIBITORS I

PHAMACOLOGY IV
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INTRODUCTION
• Penicillins and Cephalosporins are the major antibiotics
that inhibit bacterial cell wall synthesis.

• They are called beta–lactamase because of the unusual 4

membrane ring that is common to all their members.

• The beta-lactams include some of most effective, wildly

used, and well tolerated agents available for the
treatment of microbial infections.
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OVERVIEW
 Some antimicrobial drugs selectively interfere with synthesis
of the bacterial cell wall—a structure that mammalian cells
do not possess.
The cell wall is composed of a polymer called peptidoglycan
that consists of glycan units joined to each other by peptide
cross-links.
To be maximally effective, inhibitors of cell wall synthesis
require actively proliferating microorganisms; they have
little or no effect on bacteria that are not growing and dividing.
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PENICILLINS
The penicillins are among the most widely effective and the least
toxic drugs known, but increased resistance has limited their
use.

Members of this family differ from one another in the R

substituent attached to the 6-aminopenicillanic acid residue .

The nature of this side chain affects:

1. the antimicrobial spectrum
2. stability to stomach acid
3. cross-hypersensitivity
4. susceptibility to bacterial degradative enzymes (β-lactamases)
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Structure of β-lactam antibiotics

• Structural integrity of the 6-
aminopenicillanic acid
nucleus is essential for the
biologic activity of these
compounds.
• Hydrolysis of the β-lactam
ring by bacterial lactamases
yields penicilloic acid, which
lacks antibacterial activity.
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PENICILLINS (Eg, penicillin G)

• These have greatest activity against gram-positive organisms,
gram-negative cocci, and non-lactamase producing
anaerobes.
• They have little activity against gram-negative rods, and they
are susceptible to hydrolysis by beta-lactamases
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Antistaphylococcal Penicillins (Eg, Nafcillin)

• These penicillins are resistant to staphylococcal
lactamases.
They are active against staphylococci and streptococci but
not against enterococci, anaerobic bacteria, and gram-negative
cocci and rods.
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Extended-Spectrum Penicillins
These drugs retain the antibacterial spectrum of penicillin
and have improved activity against gram-negative
organisms.

• Like penicillin, however, they are relatively susceptible to

hydrolysis by lactamases.
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A. Mechanism of action
The penicillins interfere with the last step of bacterial cell
wall synthesis (transpeptidation or cross-linkage), resulting
in exposure of the osmotically less stable membrane.

Cell lysis can then occur, either through osmotic pressure

or through the activation of autolysins.

 These drugs are thus bactericidal.

Penicillins are only effective against rapidly growing organisms

that synthesize a peptidoglycan cell wall.

They are inactive against organisms devoid of this structure,

such as mycobacteria, protozoa, fungi, and viruses.
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A. Mechanism of action
• So beta-lactam antibiotics inhibit cell wall synthesis by the
following steps:
1. Binding of the drug to the specific receptors [penicillin binding
proteins(PBPs)] located in the bacterial cytoplasmic
membrane.
2. Inhibition of transpeptidase enzymes that act to cross link
peptidoglycan chains which form part of cell wall.
3. Activation of autolytic enzymes that cause lesions in bacterial
cell wall.
Enzymatic hydrolysis of the beta lactam ring results in loss of
antibacterial activity.
The formation of beta-lactamase by most staphylococci and
many gram negative organism is major mechanism of bacterial
resistance.
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1. Penicillin-binding proteins
Penicillins inactivate numerous proteins on the bacterial cell
membrane. These penicillin-binding proteins (PBPs) are
bacterial enzymes involved in the synthesis of the cell wall
and in the maintenance of the morphologic features of the
bacterium.
Exposure to these antibiotics can therefore not only prevent cell
wall synthesis but also lead to morphologic changes or lysis of
susceptible bacteria.
The number of PBPs varies with the type of organism.
Alterations in some of these target molecules provide the
organism with resistance to the penicillins.
[Note: Methicillin resistant Staphylococcus aureus (MRSA)
arose because of such an alteration.]
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2. Inhibition of transpeptidase
Some PBPs catalyze formation of the cross-linkages between
peptidoglycan chains .

Penicillins inhibit this transpeptidase-catalyzed reaction, thus

hindering the formation of cross-links essential for cell wall
integrity.

As a result of this blockade of cell wall synthesis, the “Park

nucleotide” (formerly called the “Park peptide”),
UDP-acetylmuramyl-L-Ala-DGln- L-Lys-D-Ala-D-Ala,
accumulates.
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Bacterial cell wall of gram-positive bacteria

•
•
•
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3.Production of autolysins
Many bacteria, particularly the gram positive cocci, produce
degradative enzymes (autolysins) that participate in the normal
remodeling of the bacterial cell wall.

In the presence of a penicillin, the degradative action of the

autolysins proceeds in the absence of cell wall synthesis. Thus,
the antibacterial effect of a penicillin is the result of both
inhibition of cell wall synthesis and destruction of existing cell
wall by autolysins
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Antibacterial spectrum
Factors that determine the susceptibility of PBPs to these
antibiotics include :

1. the size
2. charge
3. hydrophobicity of the particular β-lactam antibiotic
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Antibacterial spectrum
In general, gram positive microorganisms have cell walls that are
easily traversed by penicillins and, therefore, in the absence of
resistance are susceptible to these drugs.

Gram-negative microorganisms have an outer lipopolysaccharide

membrane ( envelope) surrounding the cell wall that presents a
barrier to the water- soluble penicillins. They have proteins
inserted in the lipopolysaccharide layer that act as water-filled
channels (called porins) to permit transmembrane entry.

Pseudomonas aeruginosa has restrictive porins, making this

organism intrinsically resistant to many antimicrobial agents.
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The cell wall of a gram-negative and gram-positive

bacterium
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A highly simplified diagram of the cell envelope

of a gram-negative bacterium
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The cell envelope of a gram-negative bacterium

The outer membrane, a lipid bilayer, is present in gram-
negative but not gram-positive organisms.
It is penetrated by porins, proteins that form channels providing
hydrophilic access to the cytoplasmic membrane.
The peptidoglycan layer is unique to bacteria and is much
thicker in gram-positive organisms than in gram-negative ones.
Together, the outer membrane and the peptidoglycan layer
constitute the cell wall.
Penicillin-binding proteins (PBPs) are membrane proteins that
cross-link peptidoglycan.
Lactamases, if present, reside in the periplasmic space or on
the outer surface of the cytoplasmic membrane, where they
may destroy beta-lactam antibiotics that penetrate the outer
membrane.
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Natural penicillins
Penicillin G (benzylpenicillin) is the cornerstone of therapy for
infections caused by a number of gram-positive and gram-
negative cocci, gram- positive bacilli, and spirochetes .

Penicillins are susceptible to inactivation by β-lactamases

(penicillinases).

Penicillin V has a spectrum similar to that of penicillin G, but it

is not used for treatment of bacteremia because of its poor
absorption.
Penicillin V is more acid stable than penicillin G and
is often employed orally in the treatment of infections.
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Typical therapeutic applications of penicillin G

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Antistaphylococcal penicillins
 Methicillin ,nafcillin, oxacillin and dicloxacillin are
penicillinase- resistant penicillins.

Their use is restricted to the treatment of infections caused by

penicillinase-producing staphylococci, including methicillin
sensitive S. aureus (MSSA).

Because of its toxicity (interstitial nephritis), methicillin is

not used clinically except to identify resistant strains of S.
Aureus.
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Antistaphylococcal penicillins
 Methicillin resistant Staphylococcus aureus (MRSA) is
currently a source of serious community and nosocomial
(hospital-acquired) infections and is resistant to all
commercially available β-lactam antibiotics, including
antistaphylococcal penicillins. This organism is usually
susceptible to glycopeptide vancomycin.

 The penicillinase-resistant penicillins have no activity versus

gram-negative infections.
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Extended-spectrum penicillins
Ampicillin and amoxicillin have an antibacterial spectrum similar
to that of penicillin G but are more effective against gram-
negative bacilli. Therefore, they are referred to as extended-
spectrum penicillins .

Ampicillin (with or without the addition of gentamicin) is the drug

of choice for the gram-positive bacillus , Listeria
monocytogenes and susceptible Enterococcal species.

These extended-spectrum agents are also widely used in the

treatment of respiratory infections.
Amoxicillin is employed prophylactically by dentists for patients
with abnormal heart valves who are to undergo extensive oral
surgery.
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Extended-spectrum penicillins
Resistance to these antibiotics is now a major clinical problem
because of inactivation by plasmid mediated
penicillinases.

[Note: Escherichia coli and Haemophilus influenzae are

frequently resistant.]

Formulation with a β-lactamase inhibitor, such as clavulanic

acid or sulbactam, protects amoxicillin or ampicillin, respectively,
from enzymatic hydrolysis and extends their antimicrobial
spectrum. For example, without the β-lactamase inhibitor, MSSA
is resistant to ampicillin and amoxicillin.
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Antipseudomonal penicillins
Carbenicillin , ticarcillin , and piperacillin are called
antipseudomonal penicillins because of their activity against
P. aeruginosa .

Piperacillin is the most potent of these antibiotics. They are

effective against many gram-negative bacilli, but not
against Klebsiella because of its constitutive penicillinase.

Formulation of ticarcillin or piperacillin with clavulanic acid

or tazobactam, respectively, extends the antimicrobial
spectrum of these antibiotics to include penicillinase producing
organisms.
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Penicillins and aminoglycosides

The antibacterial effects of all β-lactam antibiotics are synergistic
with the aminoglycosides.
Because cell wall synthesis inhibitors alter the permeability of
bacterial cells, these drugs can facilitate the entry of other
antibiotics (such as aminoglycosides) that might not ordinarily
gain access to intracellular target sites. This can result in
enhanced antimicrobial activity.
[Note: Although the combination of a penicillin plus an
aminoglycoside is used clinically, these drug types should never
be placed in the same infusion fluid because on prolonged
contact, the positively charged aminoglycosides form an inactive
complex with the negatively charged penicillins.]
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Stability of the penicillins to

acid or the action of
penicillinase
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Resistance
• Resistance to penicillins and other beta- lactams is due to one
of four general mechanisms:

I. inactivation of antibiotic by ß-lactamase

II. modification of target PBPs
III. impaired penetration of drug to target PBPs
IV. efflux

• ß-Lactamase production is the most common mechanism of

resistance.
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D. Pharmacokinetics
1. Administration
The route of administration of a β-lactam antibiotic is determined
by the stability of the drug to gastric acid and by the severity of
the infection.
Ticarcillin, piperacillin, and the combinations of ampicillin with
sulbactam, ticarcillin with clavulanic acid, and piperacillin with
tazobactam, must be administered intravenously (IV) or
intramuscularly (IM).
PenicillinV, amoxicillin, and amoxicillin combined with clavulanic
acid are available only as oral preparations.
Others are effective by the oral, IV, or IM routes .
Procaine penicillin G and benzathine penicillin G are
administered IM and serve as depot forms.
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D. Pharmacokinetics
2. Absorption
Most of the penicillins are incompletely absorbed after oral
administration, and they reach the intestine in sufficient amounts
to affect the composition of the intestinal flora. However,
amoxicillin is almost completely absorbed.

Absorption of all the penicillinase-resistant penicillins is

decreased by food in the stomach, because gastric emptying
time is lengthened, and the drugs are destroyed in the acidic
environment. Therefore, they must be administered 30 to 60
minutes before meals or 2 to 3 hours postprandial.
Other penicillins are less affected by food.
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D. Pharmacokinetics
3. Distribution
The β-lactam antibiotics distribute well throughout the body. All
the penicillins cross the placental barrier, but none has been
shown to be teratogenic. However, penetration into certain sites,
such as bone or cerebrospinal fluid (CSF), is insufficient for
therapy unless these sites are inflamed .
[Note: During the acute phase of infection, the inflamed
meninges are more permeable to the penicillins, resulting in an
increased ratio of the amount of drug in the central nervous
system compared to the amount in the serum.]
Penicillin levels in the prostate are insufficient to be effective
against infections.
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Enhanced penetration
of penicillin into the
cerebral spinal fluid
during inflammation
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D. Pharmacokinetics
4. Metabolism
Host metabolism of the β-lactam antibiotics is usually
insignificant, but some metabolism of penicillin G has been
shown to occur in patients with impaired renal function.
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Administration and fate of penicillin

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D. Pharmacokinetics
5. Excretion
The primary route of excretion is through (tubular) secretory
system of the kidney as well as by glomerular filtration.
Patients with impaired renal function must have dosage
regimens adjusted. Thus, the half-life of penicillin G can
increase in the presence of renal dysfunction.
Probenecid inhibits the secretion of penicillins by competing
for active tubular secretion via the organic acid transporter
and, thus, can increase blood levels.
Nafcillin, dicloxacillin and oxacillin are exceptions to the rule
and are not eliminated by the kidneys.
The penicillins are also excreted into breast milk.
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Clinical Uses
Except for oral amoxicillin, penicillins should be given 1–2
hours before or after a meal; they should not be given with food
to minimize binding to food proteins and acid inactivation.

Blood levels of all penicillins can be raised by simultaneous

administration of probenecid, 0.5 g every 6 hours orally, which
impairs renal tubular secretion of weak acids such as β-lactam
compounds.
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Penicillin
Penicillin G is a drug of choice for infections caused by
streptococci, meningococci, enterococci, penicillin-
susceptible pneumococci, non–lactamase producing
staphylococci, Treponema pallidum, spirochetes,
clostridium species, actinomyces, and other gram-positive
rods and non-lactamase producing gram-negative
anaerobic organisms.
• Depending on the organism, the site, and the severity of
infection, effective doses range between 4 and 24 million units
per day administered intravenously in four to six divided doses.
• High-dose penicillin G can also be given as a continuous
intravenous infusion.
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Penicillin
Penicillin V, the oral form of penicillin, is indicated only in
minor infections because of its relatively poor bioavailability, the
need for dosing four times a day, and its narrow antibacterial
spectrum.
Amoxicillin is often used instead.

Benzathine penicillin and procaine penicillin G for intramuscular

injection yield low but prolonged drug levels. A single
intramuscular injection of benzathine penicillin, 1.2 million units,
is effective treatment for -hemolytic streptococcal pharyngitis;

Benzathine penicillin G, 2.4 million units intramuscularly once a

week for 1–3 weeks, is effective in the treatment of syphilis.
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Penicillins Resistant to Staphylococcal Beta Lactamase

(Methicillin, Nafcillin, and Isoxazolyl Penicillins)
These semisynthetic penicillins are indicated for infection by β–
lactamase–producing staphylococci, although penicillin-
susceptible strains of streptococci and pneumococci are also
susceptible.
Listeria, enterococci, and methicillin-resistant strains of
staphylococci are resistant.
In recent years the empirical use of these drugs has increased
rates of methicillin-resistance in staphylococci.
However, for infections caused by methicillin-susceptible
strains of staphylococci , these are considered the drugs of
choice.
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Penicillins Resistant to Staphylococcal Beta Lactamase

An isoxazolyl penicillin such as oxacillin, cloxacillin, or

dicloxacillin, is suitable for treatment of mild to moderate
localized staphylococcal infections.

All are relatively acid-stable and have reasonable bioavailability.

However, food interferes with absorption, and the drugs should
be administered 1 hour before or after meals.

For serious systemic staphylococcal infections, oxacillin or

nafcillin, 8–12 g/d, is given by intravenous infusion of 1–2 g
every 4–6 hours .
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Adverse Reactions
The penicillins are remarkably nontoxic.
1.Hypersensitivity:
This is the most important adverse effect of the penicillins.
Approximately five percent of patients have some kind of reaction,
ranging from maculopapular rash (the most common rash seen with
ampicillin hypersensitivity) to angioedema (marked swelling of the lips,
tongue, and periorbital area) and anaphylaxis.
Cross-allergic reactions occur among the β-lactam antibiotics.
To determine whether treatment with a β-lactam is safe when an allergy
is noted, patient history regarding severity of previous reaction is
essential.
Ampicillin and amoxicillin can cause skin rashes that are not allergic in
nature. These rashes frequently occur when they are inappropriately
prescribed for a viral illness.
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Adverse Reactions
2. Diarrhea:
This effect, which is caused by a disruption of the normal
balance of intestinal microorganisms, is a common problem. As
with most antibiotics, pseudomembranous colitis may occur.
Large doses of penicillins given orally may lead to GI upset,
particularly nausea, vomiting, and diarrhea.
3. Neurotoxicity:
The penicillins are irritating to neuronal tissue, and they can
provoke seizures if injected intrathecally or if very high blood
levels are reached. Epileptic patients are particularly at risk.
When indicated, dosage adjustments for patients with renal
dysfunction further minimize the risk for seizure.
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Adverse Reactions
4. Hematologic toxicities:
Decreased coagulation may be observed with high doses of
piperacillin, ticarcillin and nafcillin (and, to some extent, with
penicillin G).
Eosinophilia, hemolytic anemia and other hematologic
disturbances, and vasculitis may also occur.
5. Nephritis:
All penicillins, but particularly methicillin, have the potential to cause
acute interstitial nephritis.
6. Cation toxicity:
Penicillins are generally administered as the sodium or
potassium salt. Toxicities may be caused by the large quantities
of sodium or potassium that accompany the penicillin.
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