1997 Clinical pharmacology

By Duy Thai

ANTIBIOTICS 1

• The fundamental principle of antibiotics is selective toxicity.

• We want to find an antibiotic which can target features present in bacteria but not present in human cell.
This enables effective damage to the bacteria without damage to the human cell.

• Sites of action of selected antimicrobial agents are:

1. cell wall (peptidoglycan) synthesis
2. Cell membranes
3. Peptide synthesis
4. Nucleic acid metabolism
5. Vitamin metabolism

Peptidoglycan synthesis
• The cell wall is a macromolecule made up of repeating NAM and NAG units joined together by a
glycosidic bond

NAG – NAM – NAG – NAM

• Each NAM subunit has a short tail made up of 4 amino acids:

• L ala, D glu, L lys, D ala

NAG – NAM – NAG – NAM

L ala L ala
D glu D glu
L lys L lys
D ala D ala

• The NAM residues are connected to each other via a pentaglycine (5 glycines) bridge which extends
from the 3rd amino acid in the tail (L lys) of one NAM molecule to the 4th amino acid in the tail of
another NAM molecule.
NAG – NAM
NAG – NAM
L ala
L ala D glu
D glu L lys
L lys Gly-Gly-Gly-Gly-Gly D ala
D ala

• The stages of synthesis are long, and we only need to know the steps where different drugs act:

• Cycloserine
• It is an analogue of D ala
• During synthesis, L ala is converted to D ala via an isomerase. D ala then gets converted to a
double D ala (D ala-D ala) via a synthase
• Cycloserine inhibits the action of this synthase

• The 4 amino acids which make up the tail of NAM are added one at a time. The last one, D ala, is
special because during synthesis, it exists in dipeptide form (D ala-D ala) so that the peptide tail of NAM
is actually 5 amino acids long.
• When this peptide tail is added to NAM, the whole complex is bound to the inner side of the cytoplasmic
membrane via a lipid carrier.
• When bound to the lipid membrane, NAG is added

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 1997 Clinical pharmacology
By Duy Thai

NAG – NAM

L ala
D glu
L lys Gly-Gly-Gly-Gly-Gly
D ala
D ala

This whole complex can be considered as one building block (a brick) in the formation of the cell wall

• The lipid carrier transports the “brick” from the inner membrane to the outer membrane, where the brick
gets bound to an acceptor.
• The lipid carrier then has to go back to the inner membrane to accept another “brick”.
• The joining together of 2 “bricks” via the pentaglycine bridge is done via a transpeptidase.

• Vancomycin
• Does not inhibit any enzyme
• It is physically huge and binds to the terminal D ala-D ala part of the peptide tail on NAM.
• It prevents the joining together of 2 “bricks” by physically blocking the site where attachment is
meant to occur.
• It also prevents the transfer of a brick from the inner membrane to the outer membrane.

• Bacitracin
• Prevents the dephosphorylation of the lipid carrier molecule. This means that the lipid carrier is
unable to return back to the inner membrane and receive another “brick”.

• Beta lactam antibiotics (e.g. penicillin)

• The beta lactam ring resembles the peptide bond between D ala-D ala.
• This is the bond which is recognised by the transpeptidase.
• Therefore, penicillin can bind to the transpeptidase and inhibit its action.
• Some bacteria can make enzymes which can disrupt the beta lactam ring (beta lactamases).
Bacteria which can produce beta lactamases are thus resistant to penicillin. A beta lactamase
can be thought of as a modified transpeptidase which has evolved to target the beta lactam ring
specifically.

• The spectrum of beta lactam antibiotics vary because different bacteria possess different
transpeptidases.
• When penicillin acts to disrupt synthesis of the cell wall, the excess terminal D ala residues trigger the
bacteria to produce autolysins (endopeptidases) which act on a variety of sites in the peptidoglycan cell
wall to degrade it (the bacteria undergo suicide). The cell wall is thus degraded and the bacteria
undergoes lysis due to fluid moving in (the bacteria is hypertonic). Penicillin is thus bactericidal.
• Lysozyme can also destroy the cell wall by hydrolysing the glycosidic bonds between NAM and
NAG
• If the bacteria live in a hypertonic environment, degradation of the cell wall will not kill the
bacteria because it does not undergo lysis because its inside is isoosmotic with the
environment.

• Some bacteria do not produce autolysins in response to excess D ala. In these bacteria, penicillin is
NOT bactericidal, instead it is bacteristatic. The bacteria cannot make a new cell wall and so cannot
replicate. However, the cell wall is NOT degraded, and so the bacteria do not die. These bacteria are
penicillin tolerant (not penicillin resistant).
• Penicillin is still working, but the bacteria do not complete the cycle by producing autolysins.
• Penicillin resistance means that the penicillin is completely degraded before it can work.

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 1997 Clinical pharmacology
By Duy Thai

Problems with penicillin G

• It is susceptible to degradation by beta lactamases
• It is degraded by acid in the stomach and so cannot be taken orally
• It is not effective against G- rods
• Modifications to the structure of penicillin G can produce:
• Ampicillin
• More lipid soluble than penicillin G and so can penetrate the outer lipid membrane of G-
rods in order to get to the cell wall, therefore has a broader spectrum.
• Able to be taken orally
• Clavulanic acid can be taken in conjunction with a beta lactam antibiotic because it binds to the beta
lactamase produced by the bacteria.

The bacterial cell membrane

• The bacterial cell membrane is made up of phospholipids similar to ours, and so drugs which target the
cell membrane are toxic to us as well.

• Polymyxins
• Produced by bacteria
• Too toxic for systemic use
• Act as a solvent to the cytoplasmic membrane.

• Most drugs which target membranes are useful against fungal infections.

• Polyenes (e.g. amphotericin B)

• Act by binding to sterols in cytoplasmic membrane.
• Bacteria do not have sterols, but we do (our membranes have cholesterol as a component)
• However, it is best used as an antifungal
• Fungi have ergosterol in their cell wall, which happens to attract polyenes more than does
cholesterol.
• Binding of polyenes to the cell membrane disrupts it
• There are other antifungal drugs which can interfere with ergosterol synthesis:
• Allylamines
• Azoles (ketaconazole, itraconazole can cause PVT is used in conjunction with astemizole or
terfenidine)
• Both these drugs act to inhibit the production of ergosterol synthesis. Allyamines act at an earlier stage
than azoles.

• We do not use these drugs in conjunction with polyenes! Why?

• Because azoles/allylamines inhibit the production of ergosterol. Ergosterol is the target of
amphotericin. Therefore, if there is no ergosterol around for amphotericin to act on, it will act on
cholesterol instead!

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