Burton’s Microbiology

for the Health Sciences

Module 9. Inhibiting the

Growth of Pathogens In Vivo
Using Antimicrobial Agents

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Module 9 Outline

• Introduction • Drug Resistance

• Characteristics of an Ideal • Some Strategies in the War
Antimicrobial Agent Against Drug Resistance
• How Antimicrobial Agents • Empiric Therapy
Work
• Undesirable Effects of
• Antibacterial Agents Antimicrobial Agents
• Antifungal Agents • Concluding Remarks
• Antiprotozoal Agents
• Antiviral Agents

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Introduction

• Chemotherapy is the use of any chemical (drug) to treat

any disease or condition.

• A chemotherapeutic agent is any drug used to treat any

condition or disease.

• An antimicrobial agent is any chemical (drug) used to

treat an infectious disease, either by inhibiting or by
killing pathogens in vivo. Some antimicrobial agents are
antibiotics.

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Introduction—(cont.)

• Drugs used to treat bacterial diseases are called

antibacterial agents; those used to treat fungal diseases,
antifungal agents; those used to treat protozoal diseases,
antiprotozoal agents; and those used to treat viral
diseases, antiviral agents.
• An antibiotic is a substance produced by a microorganism
that kills or inhibits the growth of other microorganisms.
• Antibiotics that have been chemically modified to kill a
wider variety of pathogens or reduce side effects are
called semisynthetic antibiotics; examples include
semisynthetic penicillins, such as ampicillin and
amoxicillin.

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 The Discovery of Penicillin by
Alexander Fleming

Alexander Fleming

(A) Colonies of Staphylococcus aureus

are growing well in this area of the plate.
(B) Colonies are poorly developed in this
area of the plate because of an antibiotic
(penicillin) being produced by a colony of
Penicillium notatum (a mould), shown at
C.

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Characteristics of an Ideal Antimicrobial
Agent

• An ideal antimicrobial agent should

– Kill or inhibit the growth of pathogens
– Cause no damage to the host
– Cause no allergic reaction in the host
– Be stable when stored in solid or liquid form
– Remain in specific tissues in the body long enough to
be effective
– Kill the pathogens before they mutate and become
resistant to it

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How Antimicrobial Agents Work

• The five most common mechanisms of action of

antimicrobial agents are:
– Inhibition of cell wall synthesis
– Damage to cell membranes
– Inhibition of nucleic acid synthesis (either DNA or
RNA synthesis)
– Inhibition of protein synthesis
– Inhibition of enzyme activity

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Antibacterial Agents

• Bacteriostatic drugs inhibit growth of bacteria, whereas

bactericidal drugs kill bacteria.
• Sulfonamide drugs inhibit production of folic acid (a
vitamin) in those bacteria that require p-aminobenzoic
acid to synthesize folic acid; without folic acid, bacteria
cannot produce certain essential proteins and die.
– Sulfa drugs are competitive inhibitors; they are
bacteriostatic.
• In most Gram-positive bacteria, penicillin interferes with
the synthesis and cross-linking of peptidoglycan, a
component of cell walls. By inhibiting cell wall synthesis,
penicillin destroys the bacteria.

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The Effect of Sulfonamide Drugs

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Antibacterial Agents—(cont.)

• Colistin and nalidixic acid destroy only Gram-negative

bacteria; they are referred to as narrow-spectrum
antibiotics.
• Antibiotics that are destructive to both Gram-positive and
Gram-negative bacteria are called broad-spectrum
antibiotics (e.g., ceftriaxone, ciprofloxacin, and
tetracycline).
• Multidrug therapy
– Sometimes one drug is not sufficient; two or more
drugs may be used simultaneously, as in the
treatment of tuberculosis.

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Antibacterial Agents—(cont.)

• Synergism versus antagonism

– Synergism is when two antimicrobial agents are used
together to produce a degree of pathogen killing that
is greater than that achieved by either drug alone.
Synergism is a good thing!
– Antagonism is when two drugs actually work against
each other. The extent of pathogen killing is less
than that achieved by either drug alone. Antagonism
is a bad thing!

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Some Major Categories of Antibacterial
Agents

• Penicillins (bactericidal; interfere with cell wall

synthesis)
• Cephalosporins (bactericidal; interfere with cell wall
synthesis)
• Carbapenems (bactericidal; interfere with cell wall
synthesis)
• Tetracyclines (bacteriostatic; inhibit protein synthesis)
• Aminoglycosides (bactericidal; inhibit protein synthesis)
• Macrolides (bacteriostatic at lower doses; bactericidal at
higher doses; inhibit protein synthesis)
• Fluoroquinolones (bactericidal; inhibit DNA synthesis)

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Antifungal Agents

• Most antifungal agents work in one of three ways:

– By binding with cell membrane sterols (e.g., nystatin
and amphotericin B)
– By interfering with sterol synthesis (e.g., fluconazole
and miconazole; echinocandins)
– By blocking mitosis or nucleic acid synthesis (e.g.,
griseofulvin and 5-flucytosine)
• Antifungal agents and antiprotozoal agents tend to be
more toxic to the patient because, like the infected
human, they are eukaryotic organisms.

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Antiprotozoal Agents

• Antiprotozoal agents are usually toxic to the host.

• Antiprotozoal agents work by

– Interfering with DNA and RNA synthesis (e.g.,

chloroquine, pentamidine, and quinacrine)

– Interfering with protozoal metabolism (e.g.,

metronidazole)

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 Antiviral Agents

• Antiviral agents are the newest weapons in antimicrobial

methodology.
• Difficult to develop these agents because viruses are
produced within host cells.
• Some drugs have been developed that are effective in
certain viral infections, but not others; they work by
inhibiting viral replication within cells.
• “Cocktails” (several antiviral drugs that are administered
simultaneously) are being used to treat HIV infection.

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 Drug Resistance: “Superbugs”
• Superbugs are microbes (mainly bacteria) that have
become resistant to one or more antimicrobial agents.
Infections caused by superbugs are difficult to treat!
• Bacterial superbugs include
• methicillin-resistant Staphylococcus aureus (MRSA)
• vancomycin-resistant Enterococcus spp. (VRE)
• multidrug-resistant Mycobacterium tuberculosis
(MDRTB)
• multidrug-resistant strains of Acinetobacter,
Burkholderia, Pseudomonas
• Neisseria gonorrhoeae
• carbapenemase-producing Klebsiella pneumoniae (KPC)

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 Superbugs

Hospitals are notorious

havens for multidrug-
resistant microbes.

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Drug Resistance: How Bacteria Become
Resistant to Drugs

• Some bacteria are naturally resistant because they lack

the specific target site for the drug or the drug is unable
to cross the organism’s cell wall or cell membrane and,
thus, cannot reach its site of action. Resistance of this
type is known as intrinsic resistance.
• If bacteria that were once susceptible to a particular drug
become resistant, this is called acquired resistance.
• Before a drug enters a bacterial cell, it must first bind to
proteins on the surface of the cell; these proteins are
called drug-binding sites. A chromosomal mutation that
affects the structure of a drug-binding site can prevent
the drug from binding, resulting in drug resistance.

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Drug Resistance: How Bacteria Become
Resistant to Drugs—(cont.)
• To enter a bacterial cell, a drug must be able to pass
through the cell wall and cell membrane; chromosomal
mutations may alter the structure of the cell membrane,
thus preventing the drug from entering the cell; this
results in drug resistance.
• Bacteria can develop the ability to produce an enzyme
that destroys or inactivates a drug.
– Many bacteria have become resistant to penicillin
because they have acquired the gene for penicillinase
production during conjugation.
• A plasmid that contains multiple genes for drug
resistance is known as a resistance factor (R-factor).

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Drug Resistance: How Bacteria Become
Resistant to Drugs—(cont.)
• Bacteria can also become resistant to drugs by
developing the ability to produce multidrug-resistance
(MDR) pumps (also known as MDR transporters or efflux
pumps).
– An MDR pump enables the cell to pump drugs out
before they can damage or kill the cell.
• Summary: Bacteria can acquire resistance to
antimicrobial agents by chromosomal mutation or by the
acquisition of new genes by transduction, transformation,
and, most commonly, by conjugation.

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Mechanisms by Which Bacteria Become
Resistant to Antimicrobial Agents

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 Drug Resistance: β-Lactamases
• Every penicillin, cephalosporin, and carbapenem molecule
contains a double-ringed structure (referred to as a “house and
garage”). The “garage” is known as the β-lactam ring.
• Some bacteria produce enzymes, β-lactamases, that destroy
this ring; when the β-lactam ring is destroyed, the drug no
longer works.
– There are three types of β-lactamases:
– Penicillinases
– Cephalosporinases
– Carbapenemases
– Drug companies have developed special drugs that combine a
β-lactam antibiotic with a β-lactamase inhibitor (e.g.
piperacillin/tazobactam)

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Sites of β-Lactamase Attack on Penicillin
and Cephalosporin Molecules

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Some Strategies in the War Against Drug
Resistance
• Education of health care • Patients should destroy any
professionals and patients excess or outdated
• Patients should stop medications
demanding antibiotics every • Antibiotics should not be
time they are, or their child
is, sick used in a prophylactic
manner
• Physicians should not be
pressured by patients and • Health care professionals
should prescribe drugs only should practice good
when warranted infection control
• Clinicians should prescribe a • Patients should take drugs in
narrow-spectrum drug if manner prescribed
laboratory results indicate
that it kills the pathogen

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Empiric Therapy
• Empiric therapy is when drug therapy is initiated before
laboratory results are available (i.e., before the pathogen
is identified and/or before susceptibility test results are
available).
– Empiric therapy is sometimes necessary to save a
patient’s life.
– Clinicians make an “educated guess” based on past
experience with the type of infectious disease and
the most effective drugs.
• Clinicians must take a number of factors into
consideration before prescribing antimicrobial agents.

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Empiric Therapy: Factors to Be Considered—
(cont.)
• If pathogen identity is • Is the drug the hospital
known, use the “pocket formulary?
chart” of antimicrobial
susceptibility test data from • Site of the infection?
the past year. • What other medication(s) is
• Is the patient allergic to any the patient taking?
antimicrobial agents? • What other medical problems
• What is the age of the does the patient have?
patient? • Is the patient leukopenic or
• Is the patient pregnant? immunocompromised?

• Inpatient or outpatient? • What is the cost of the

drug(s)?

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 Example of a Pocket Chart for Aerobic
Gram-Negative Bacteria

The chart provides a

quick reference
whenever empiric
therapy is necessary.

Note: this chart is different

from the one in the textbook.

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Undesirable Effects of Antimicrobial
Agents
• Reasons why antimicrobial agents should not be used
indiscriminately:
– Organisms susceptible to the agent will die, but
resistant ones will survive; this is known as selecting
for resistant organisms.
– The patient may become allergic to the agent.
– Many agents are toxic to humans and some are very
toxic.
– With prolonged use, a broad-spectrum antibiotic may
destroy the normal flora, resulting in an overgrowth
of bacteria known as a superinfection, such as
Clostridium difficile-associated diarrhea.

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Selecting for Drug-Resistant Organisms

A. Indigenous microbiota of a
patient before antibiotic
therapy (S, susceptible; R,
resistant).
B. After antibiotic therapy has
been initiated.
C. Resistant organisms multiply
and become the predominant
organisms.

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