Antibiotics: Classification and

Mechanisms of Action
A/Prof Olga Perovic, Principal Pathologist, Center for
Healthcare Associated Infections Antimicrobial Resistance and
Mycoses, National Institute for Communicable Diseases at
NHLS and Associate Professor at WITS

Date: 2/4/2019
WHO GLASS training workshop on AMR
 Objectives
• To explain general principles of
antibiotics
• To classify antibiotics
• To describe and understand
mechanisms of action of antibiotics.
 What are antibiotics by
definition?
• Antibiotics are substances produced by
microorganisms which are antagonistic (opposed) to
the growth or life of others bacteria.
– Difference between human (eukaryotic) and bacterial
(prokaryotic) cell structure allow antibiotics to target
bacterial structures but not host cell function-this
phenomenon is called as selective toxicity
• Bactericidal (killing) and bacteriostatic (growth inhibition)
– No harm to patient.

12/01/2023 3
 Evolution of antibiotics

12/01/2023 4
 When to use them?
1. Is antibiotics treatment indicated based on clinical findings?
Evident bacterial infection
Localized infections: pneumonia, pyelonephritis etc.
Infections with characteristic clinical findings: cellulitis,
bacterial arthritis.
Inflammatory markers: leukocytosis, neutrophilia,
lymphocytopenia, left shift, presence of bands, elevated C-
reactive protein (CRP) and procalcitonin
(PCT).
2. What is emergency of the patients condition
Non-critical conditions: mild infection, which does not require
treatment until the diagnosis is not established

Climate and Culture Survey

Critical conditions: the patient with suspected severe infection:
Febrile neutropenia
Bacterial meningitis
Embracing Diversity, Building Unity
Necrotizing cellulitis
Severe sepsis and septic shock
12/01/2023 5
Title
 Role of the diagnostic stewardship
1. Have appropriate clinical specimens been obtained, examined and cultured?
MC&S Microscopy Gram stain; Culture - anaerobic and aerobic cultures; Latex
agglutination
Antibiotic Susceptibility Testing (AST)-Empirical antibiotic treatment must be modified when
the AST becomes available.
In consultation with microbiologist , additional tests such as antibiotic minimum
inhibitory concentration (MIC), antibiotic assay, serum bactericidal activity and
synergy tests of antibiotic combinations may be useful in serious infections (e.g.
endocarditis and in immunocompromised
patients). In vitro resistance generally predicts clinical ineffectiveness but
not always. The pharmacokinetics and pharmacodynamics (e.g. penetration into relevant
tissues) as well as the spectrum of activity of the antibiotic must be considered.
Antibiotic pharmacokinetic principles should determine the dosage and frequency
of antibiotic regimens.
2. Which organisms are most likely to be causing the infection?
Type of focal infection
Age: bacterial meningitis of newborns – group B streptococci, Gram-negative
bacteria
Epidemiologic features: hospital vs. community acquired infections, prior antibiotic
use, etc.
3. If multiple antibiotics are available to treat pathogen, which agent would be the best?
Prior antibiotic allergies
Antibiotic penetration - CNS infection, abscesses etc.
pH - aminoglycosides are much more effective in an alkaline medium
12/01/2023 Potential side effects - linezolid – occurrence of pancytopenia after month of 6
 General principles, Right X 3
1. All appropriate microbiological specimens, including blood cultures,
should be obtained before commencing antibiotic therapy. An immediate
Gram-stained report may indicate the appropriate antibiotic to use;
2. Blood cultures should be taken from a venepuncture site, after adequate
skin antisepsis, and not from an intravenous or arterial catheter.
3. Antibiotics should be administered without delay.
4. The decision for empiric therapy, i.e. cover for the most ‘likely’ organisms
causing any specific infection, must include various factors such as the
site of the infecting organism (respiratory tract pathogens differ from
those of abdominal infections), community versus hospital-associated
infection; recent previous antibiotic prescription; ward versus ICU-
acquired infection and knowledge of the organisms commonly grown in
patients in any specific area.
5. Use a narrow-spectrum antibiotic whenever possible,
1. appropriate empirical choice for nosocomial sepsis, requires initial broad-spectrum
antibiotics, even a combination, until culture and AST results are back and de-escalation
should be implemented. Inappropriate and/or delayed appropriate antibiotic use in the
ICU has been shown to have an impact on morbidity and mortality.
6. Evaluate the clinical response to treatment.

12/01/2023 7
 Classification of antibiotics

• Antibiotic activity
– Bactericidal (the agent kills the bacteria) vs.
bacteriostatic (the agent inhibits growth of the
organism)
• Chemical structure
– Natural are metabolic by-products of soil
microorganisms including fungi.
– Semi-synthetic
– Synthetic
• Mechanisms of action.

12/01/2023 8
 Antibiotics mechanisms of action

 Effects on cell wall integrity

 Inhibition of protein synthesis
• Interference with nucleic acid metabolism
 Inhibition of enzymes that synthesize folic acid,
which automatically decreased synthesis of
nucleotides and eventually inhibition of bacterial
growth.

12/01/2023 9
 Inhibition of cell wall synthesis
ß-lactams and glycopeptides

12/01/2023 10
 The
structure of
cell wall

12/01/2023 11
 Mechanism of action of ß-lactams
• Penicillin and other ß-lactam antibiotics inactivate a set of
transpeptidases (PBPs) that catalyze the final cross-linking
reactions of peptidoglycan synthesis.
• Penicillin inhibits these enzymes by inactivating them,
forming an penicilloyl-enzyme complex.
PBPs are responsible for the assembly, maintenance, and regulation of the
peptidoglycan structures

12/01/2023 12
Classification of penicillins and cephalosporins
• Natural penicillins • Cephalosporins
– Penicillin G potassium – First generation
– Penicillin V phenoxymethyl • Cefazolin
• Semisynthetic Penicillins – Second generation
– Penicillinase-resistant penicillins • Cefuroxim
• Cloxacillin • Cefoxitin
• Methicillin – Third generation
– Aminopenicillins • Cefotaxime
• Ampicillin
• Ceftriaxone
• Amoxicillin
– Carboxypenicillins
• Ceftazidime
• Carbenicillin and ticarcillin – Fourth generation
– Ureidopenicillins • Cefepime
• Piperacillin • cefpirome

12/01/2023 13
 Other ß-lactam antibiotics
• Carbapenems
– Ertapenem
– Imipenem-high affinity to high-molecular-weight PBPs.
– Meropenem
– Doripenem
• Monobactams
– Aztreonam
• ß-lacatmase inhibitors protects from the hydrolytic
activity of ß-lactamases by “suicide” inactivation
(inhibitor is hydrolyzed):
– Amoxicillin-clavulanate
– Piperacillin-tazobactam
– Ampicillin/sulbactam
– Ceftolozane-tazobactam

12/01/2023 14
 Glycopeptides
• Mechanism of action
– Inhibit second stage of cell wall peptidoglycan
synthesis by binding to the (D-alanyl-D-alanine
precursor) peptide side chain, which fits into a
“pocket” in the vancomycin molecule and that
prevents assemble of the murein monomer into
peptidoglycan.
• These are representative antibiotics:
– Vancomycin
– Teicoplanin

12/01/2023 15
 Inhibition of transpeptidation

12/01/2023 16
Macrolides, Lincosamide and Streptogramins-MLS (chemically
unrelated but similar biologic properties) inhibit protein
synthesis at 50s ribosomal subunit

Macrolides Lincosamide Streptogramins

erythromycin clindamycin Streptogramins:
quinupristin and
dalfopristin for
treatment of GRE
azithromycin and GISA

clarithromycin

12/01/2023 17
 Inhibition of protein synthesis
• By interfering with protein synthesis at the
ribosomal level.
• By binding of the agent to either the 50s or
30s ribosomal subunit.
• The final outcome which result in
inhibition or killing of the organism
depends on whether this binding is
reversible or irreversible.

12/01/2023 18
 Macrolides
• Mechanisms of action
• A single molecule of
the antibiotic
reversibly binds to the
50S ribosomal
subunit, and lead to
inhibition of protein
synthesis.
• Other activities
• Anti-inflammatory
activities

12/01/2023 19
 Macrolide members

• Macrolides are divided into 14, 15, and 16 members:

– 14-members are erythromycin, clarithromycin.
• Ketolides are semisynthetic 14-member-ring macrolides
with a 3-keto instead of a 3-OH, and possess:
– Strong acid stability
– Higher in vitro activity against gram positive cocci
– Represented with telithromycin
– 15-member is azithromycin
– 16-members are carbomycin, josamycin and rokitomycin.

12/01/2023 20
 Lincosamide - clindamycin

• Clindamycin binds to 50S ribosomal binding site as

other macrolides.
• At low concentrations, clindamycin inhibits
production of toxic-shock and other toxins by GAS
and S. aureus.
• Clindamycin is a bacteriostatic agent, but has a
concentration-dependent bactericidal activity
against staphylococci, streptococci, anaerobes, and
H. pylori.

12/01/2023 21
 Aminoglycosides

Natural Natural- Semisynthetic

Micromonospora
streptomycin gentamicin amikacin
neomycin sisomicin netilmicin
kanamycin
paramomycin
tobramycin

12/01/2023 22
 Mechanism of action of aminoglycosides

• Inhibition of protein
synthesis by irreversible
binding to the 30 S
bacterial ribosomal
subunit.
• By displacing the cations
(Ca and Mg), which
makes outer membrane
permeable and
Aminoglycosides interfere with the
providing entry of the proofreading process that helps
antibiotic. assure the accuracy of translation.

12/01/2023 23
 Tetracyclines
• Mechanism of action
– They penetrate by a pH-
dependent process (passive
diffusion) trough hydrophilic
pores.
– And trough cytoplasmic
membrane by an energy
dependent active transport
system
– Once inside the cell they binds
reversibly to the 30S
ribosomal subunit.

12/01/2023 24
Antibiotics inhibition of protein synthesis

Fusidic acid Chloramphenicol

• The exact mechanisms by • Introduced in 1949, is one
which fusidic acid inhibit of many antibiotics derived
protein synthesis have not from soil organisms of the
been fully explained. genus Streptomyces.
• Mechanism of action
• Fusidic acid blocks
– Interferes with protein
elongation of polypeptide synthesis by binding to the
chain, by inhibiting prokaryotic 50S ribosomal
ribosome-elongation factor. subunit.

12/01/2023 25
 Linezolid- the first oxazolidinone
• Linezolid acts as an inhibitor of bacterial
protein synthesis by blocking the formation
of the 70s ribosomal initiation complex.
• Against most susceptible bacterial species,
linezolid is bacteriostatic.
• Linezolid is bactericidal against pneumococci,
GAS and anaerobes.

12/01/2023 26
 Linezolid mechanism of action

12/01/2023 27
Antibiotics that interfere with DNA synthesis

• Quinolones
• Metronidazole
• Rifampicin

12/01/2023 28
 Mechanism of action of fluoroquinolones
Quinolones acts on enzymes -topoisomerases II (DNA gyrase in gram-negative
bacteria) and topoisomerase IV (in gram positive bacteria). DNA gyrase inserts
negative supercoils into DNA.

12/01/2023 29
 Classification of quinolones

• Narrow spectrum • Expanded spectrum

– nalidixic acid – levofloxacin
• Broad spectrum – moxifloxacin
– ciprofloxacin
– ofloxacin
– norfloxacin

12/01/2023 30
 Metronidazole
Mechanism of action
– Enters bacteria via cell diffusion
– Activates via single reduction step by
bacteria forms radicals reacts
with nuclear acid cell death by
decreased intracellular
concentration of unchanged drug
which generates
intermediate products which are
toxic to the cell. These toxic
transitory products interact with
DNA, causing standard breaks and
unwinding, resulting in cell death.
– Spectrum of activity:
Anaerobic bacteria,
microaerophilic bacteria, protozoa
12/01/2023 31
 Rifampicin
• In the 1960s derived from Streptomyces
mediterranei.
• First line treatment of Mycobacterium
tuberculosis.
• Bactericidal effect by inhibition of DNA
synthesis.
• Adverse effects
• Hepatotoxicity
• Early phase hyperglycemia
• Immune dysfunction (decreased albumin and T cell
counts)

12/01/2023 32
 Antibiotics that inhibit folate synthesis
• Sulfonamide is similar in • Trimethoprim (TMP) is a
structure to para- structural analogue of
aminobenzoic acid (PABA), dihydropteroic acid, the first
which is used for folic acid step in the synthesis of
synthesis (necessary for
synthesis of nucleotides in dihydrofolic acid sequential
bacterial and mammalian inhibitor of folic acid as well.
cells). • The combination TMP-SMX
• Inhibition of bacterial growth is synergistic against a wide
by competitively incorporating spectrum of bacterial
of PABA into tetrahydropteroic species.
acid.

12/01/2023 33
 Steps trough folate synthesis

• Pathway for the

synthesis of
tetrahydrofolic Acid, a
cofactor needed for
the synthesis of DNA
and RNA nucleotides

12/01/2023 34
 Overview of antibiotics and their actions

12/01/2023 35
 New Antibiotics

Tigecyclines
• Broad spectrum glycylcycline
• Semi-synthetic derivative of Minocycline
• No activity against Pseudomonas aeriginosa due to
efflux by MexXY-OprM (Jian Li Lancet infect Dis 2006

• Activity against gram negative, gram positive, atypical,

anaerobic and resistant bacteria.
• This includes activity against MRSA, VRE and penicillin resistant
Streptococcus pneumoniae.
• Unlike existing tetracyclines, tigecycline is only available as an
intravenous preparation, is administered twice daily.

12/01/2023 36
 Mechanism of action

Glycylcyclines overcome key mechanisms of resistance

Glycylcyclines bind to the ribosome with five times higher affinity
than tetracycline
Binds to the 30S ribosomal and blocks the entry of amino-acyl
tRNA to the acceptor site
Inhibit protein synthesis and bacterial growth
Tigecyclines binds to additional sites of the ribosome in a manner
not seen before, interfering with the mechanism of ribosomal
protection proteins
Tigecyclines is not interfered by macrolide or tetracycline efflux
12/01/2023pumps. 37
 Daptomycin

12/01/2023 38
 Ceftolozane and tazobactam

• Ceftolozane exhibits greater affinity for all essential PBPs

• In clinical trials, some but not all isolates of E. coli and K. pneumoniae producing beta-
lactamases were susceptible to ZERBAXA (MIC ≤2 mcg/mL)
• ZERBAXA is not active against bacteria that produce serine carbapenemases (K.
pneumoniae carbapenemase [KPC]) and metallo-beta-lactamases
• As shown in separate, surveillance studies CTX-M is the most prevalent ESBL
group
• The 3 most prevalent P. aeruginosa mechanisms of resistance are chromosomal
AmpC, loss of outer membrane porin, and upregulation of efflux pumps .

12/01/2023 39
Thank you for attention!