pharmaceutical microbiology i. antimicrobial procedures and chemotherapy

231 Pages·2010·1.68 MB·English

department of medical microbiology
medical and health science center
university of debrecen
dr. Krisztina szarka – dr. gábor Kardos
pharmaceutical microbiology i.
antimicrobial procedures and chemotherapy
lecture notes for pharmacy students
debrecen university press
2010
reviewed by
prof. dr. lajos gergely
isbn 978-963-318-021-1
© debreceni egyetemi Kiadó debrecen university press,
beleértve az egyetemi hálózaton belüli elektronikus terjesztés jogát is
Kiadta a debreceni egyetemi Kiadó debrecen university press
Felelős kiadó: Dr. Virágos Márta
Készült a de sokszorosítóüzemében, 2010-ben
10-328
Table of contents
Sterilization and disinfection (Krisztina Szarka)...............................................................................................1
The kinetics of the destruction of microbes........................................................................................................1
Factors influencing the efficacy of sterilization/disinfection..............................................................................3
Physical methods for sterilization and disinfection............................................................................................5
High Temperature..........................................................................................................................................5
Mechanisms of thermal injury.........................................................................................................5
Application of moist heat................................................................................................................5
Application of dry heat....................................................................................................................6
The control of the efficacy of heat sterilization...............................................................................6
Cold, freezing................................................................................................................................................7
Radiation.......................................................................................................................................................7
Ultraviolet (UV) radiation...............................................................................................................7
Ionizing radiation............................................................................................................................8
Ultrasound.....................................................................................................................................................9
Filtration........................................................................................................................................................9
Gas sterilization, plasma sterilization................................................................................................................9
Spectrum of efficacy of physical methods.........................................................................................................10
Chemical methods for sterilization and disinfection........................................................................................11
Determination of the efficacy of the disinfectants.......................................................................................11
Groups of disinfectants................................................................................................................................15
Disinfectants damaging the cell membrane.............................................................................................16
Surface-active compounds............................................................................................................16
Cation-active tensides...............................................................................................................16
Anion-active tensides................................................................................................................17
Non-ionic tensides....................................................................................................................18
Amphoteric tensides.................................................................................................................18
Alcohols.........................................................................................................................................19
Phenol and phenolics....................................................................................................................19
Biguanides.....................................................................................................................................20
Protein denaturing agents........................................................................................................................21
Acids and alkali compounds..........................................................................................................21
Agents modifying the functional groups of proteins and nucleic acids...................................................22
Heavy metal compounds...............................................................................................................22
Oxidizing agents............................................................................................................................23
Halogen derivatives..................................................................................................................23
Ozone.......................................................................................................................................24
Peroxides..................................................................................................................................25
Dyes...............................................................................................................................................25
Aniline dyes..............................................................................................................................26
Acridine dyes............................................................................................................................26
Alkylating agents...........................................................................................................................26
Aldehydes.................................................................................................................................27
Ethylene-oxide..........................................................................................................................28
β-propiolactone.........................................................................................................................28
Disinfectant combinations and disinfectant systems...............................................................................28
Spectrum of activity of disinfectants.......................................................................................................29
Microbial contamination and spoilage of pharmaceuticals. Preservation of pharmaceuticals.......................30
Sensitivity of formula components to microbial degradation..................................................................30
Therapeutic agents (drugs)...........................................................................................................30
Surface-active agents....................................................................................................................31
Organic polymers..........................................................................................................................31
Moisturizing agents.......................................................................................................................31
Fats and oils..................................................................................................................................31
Sweeteners, aromas and colouring agents....................................................................................31
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Table of contents
Preservatives and disinfectants.....................................................................................................32
Visible signs of microbial degradation in pharmaceutical formulae.......................................................32
Factors influencing the microbial spoilage.............................................................................................32
Type and number of colonizing microorganisms..........................................................................32
Nutrients........................................................................................................................................33
Moist content – water activity.......................................................................................................33
Redox potential.............................................................................................................................34
Storage temperature......................................................................................................................34
pH..................................................................................................................................................34
Packaging......................................................................................................................................34
Resistance of microorganisms in pharmaceutical products..........................................................35
Health risk arising from microbial contamination...................................................................................35
Potential sources and prevention of contamination.................................................................................36
Contamination during the manufacturing process........................................................................36
Production in the hospital pharmacy – magistral formulations.................................................36
Water quality.......................................................................................................................36
Manufacturing environment.................................................................................................36
Packaging.............................................................................................................................37
Contamination during use.............................................................................................................37
Contamination of human origin................................................................................................37
Environmental sources..............................................................................................................38
Contamination originating from devices and equipment..........................................................38
Factors influencing the outcome of pharmaceutical-transmitted infections............................................38
Type and extent of microbial contamination.................................................................................39
Mode of administration.................................................................................................................39
Resistance of the patients to infection...........................................................................................39
Preservation of pharmaceutical products................................................................................................40
Factors affecting the efficacy of preservatives..............................................................................40
Control of the microbiological quality of the products...........................................................................41
Quality assurance during formula design and development.........................................................41
Good pharmaceutical manufacturing practice.............................................................................42
Quality control processes..............................................................................................................42
Resistance against disinfectants.......................................................................................................................43
Bacterial resistance to disinfectants.............................................................................................................44
Natural resistance of bacteria..................................................................................................................44
Intrinsic resistance of Gram positive bacteria..............................................................................44
Intrinsic resistance of Gram negative bacteria.............................................................................45
Intrinsic resistance of mycobacteria.............................................................................................45
Intrinsic resistance of bacterial spores.........................................................................................45
Biofilm production as a mechanism of the intrinsic resistance.....................................................46
Acquired resistance of bacteria to disinfectants......................................................................................46
Resistance of bacteria transferred by mobile genetic elements.....................................................47
Resistance of bacteria due to mutations........................................................................................47
Phenotypic adaptation as a part of acquired resistance...............................................................47
Fungal resistance to disinfectants................................................................................................................48
Viral resistance to disinfectants...................................................................................................................48
Protozoal resistance to disinfectants............................................................................................................49
Resistance of prions to disinfectants............................................................................................................49
Disinfectant policy............................................................................................................................................49
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Table of contents
Antimicrobial chemotherapy (Gábor Kardos).................................................................................................52
Classification of antimicrobial agents..............................................................................................................52
Principles of antibacterial and antifungal therapy..........................................................................................53
Resistance to antibiotics...................................................................................................................................55
Classification of resistance..........................................................................................................................55
Development and spread of resistance.........................................................................................................56
Genetic background of resistance................................................................................................................58
Possible mechanisms of resistance..............................................................................................................59
Alteration of the chemical structure of the drug......................................................................................59
Cleavage.............................................................................................................................................59
Enzymatic modification.....................................................................................................................60
Decrease of intracellular concentration of the drug................................................................................60
Low permeability/permeability decrease............................................................................................60
Active efflux.......................................................................................................................................61
Changes connected with the target..........................................................................................................62
Target modification............................................................................................................................62
Overproduction of the target..............................................................................................................62
Production of a new target.................................................................................................................62
Development of a metabolic bypass...................................................................................................62
Protection of the target.......................................................................................................................63
Decreased activation...............................................................................................................................63
Tolerance to antibiotics...............................................................................................................................63
Antibiotic susceptibility testing...................................................................................................................64
Antibiotic susceptibility testing methods................................................................................................65
Quantitative methods..........................................................................................................................66
Methods to determine MIC............................................................................................................66
Agar dilution method................................................................................................................66
Broth dilution method...............................................................................................................67
E-test®......................................................................................................................................68
Determination of MBC/MFC.........................................................................................................68
Determination of SBT....................................................................................................................68
Time-kill tests (curves)..................................................................................................................69
Checkerboard dilution..................................................................................................................69
Semiquantitative methods..................................................................................................................71
Breakpoint determination..............................................................................................................71
Resistance screening.....................................................................................................................71
Disc-diffusion (Kirby-Bauer) method............................................................................................71
Semiautomated and automated susceptibility testing.........................................................................72
Comparison of susceptibility testing methods....................................................................................72
Direct demonstration of resistance mechanisms.................................................................................73
Demonstration of proteins responsible for resistance...................................................................73
Demonstration of b-lactamases................................................................................................73
Demonstration of ESBLs..........................................................................................................73
Demonstration of MBLs...........................................................................................................74
Demonstration of PBP2a responsible for b-lactam resistance of MRSA.................................74
Direct demonstration of resistance genes.....................................................................................74
Interpretation of in vitro susceptibility....................................................................................................74
Using antibiotic susceptibility testing for diagnostic purposes...............................................................75
Mathematical description of the antibiotic effect.............................................................................................75
Pharmacodynamic parameters.....................................................................................................................76
Pharmacodynamic model systems...............................................................................................................78
In vitro models........................................................................................................................................78
Animal models........................................................................................................................................78
Using clinical data..................................................................................................................................78
Pharmacodynamics of resistance development............................................................................................78
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Table of contents
Development of antimicrobial agents...............................................................................................................80
Sources of compounds with antimicrobial activity.................................................................................80
The drug development process...............................................................................................................81
Problems with development of new antibiotics.......................................................................................82
Antibiotic policy (antibiotic stewardship)........................................................................................................83
Data collection........................................................................................................................................84
Measuring antibiotic consumption.....................................................................................................85
Regulation of antibiotic usage.................................................................................................................86
Training..................................................................................................................................................88
Antibacterial agents.........................................................................................................................................89
Drugs targeting cell wall synthesis..............................................................................................................89
b-lactam antibiotics......................................................................................................................89
Penicillins.................................................................................................................................90
Early penicillins...................................................................................................................90
b bbb -lactamase- (penicillinase-) stable penicillins....................................................................90
Broad spectrum penicillins..................................................................................................91
Aminopenicillins.............................................................................................................91
Carboxypenicillins..........................................................................................................91
Ureidopenicillins.............................................................................................................91
Temocillin............................................................................................................................92
Mecillinam (amdinocillin)...................................................................................................92
Penicillins protected with β-lactamase inhibitor..................................................................92
Cephalosporins.........................................................................................................................93
1st generation (drugs licensed before 1978).........................................................................94
2nd generation (drugs licensed between 1978-1981)............................................................94
3rd generation (drugs licensed after 1981)............................................................................95
4th generation.......................................................................................................................97
‘5th generation’.....................................................................................................................97
Cefamycins..........................................................................................................................97
Carbapenems............................................................................................................................98
Monobactams...........................................................................................................................99
Mechanism of resistance to β-lactam antibiotics..........................................................................99
Resistance due to production of b-lactamases..........................................................................99
Important β-lactamases by functional groups.....................................................................101
Phylogenetic classification of the clinically most important b -lactamases........................105
Clinically important β-lactamases by groups of bacteria...................................................105
Resistance conferred by alteration of PBPs............................................................................106
Resistance caused by alternative cell wall synthesis...............................................................107
Resistance based on decreased permeability (slower drug uptake)........................................107
Efflux-based resistance...........................................................................................................107
Glycopeptides..............................................................................................................................108
Mechanisms of glycopeptide resistance......................................................................................109
Lipoglycopeptides.......................................................................................................................110
Daptomycin.................................................................................................................................111
Fosfomycin (fosfonomycin).........................................................................................................111
Mechanisms of fosfomycin resistance.........................................................................................111
Lipoglycodepsipeptides...............................................................................................................111
Drugs targeting the cell membrane............................................................................................................112
Polymyxins..................................................................................................................................112
Daptomycin.................................................................................................................................113
Lipoglycopeptides.......................................................................................................................113
Drugs targeting the ribosome.....................................................................................................................115
Aminoglycosides and aminocyclitoles.........................................................................................115
Mechanisms of aminoglycoside resistance..................................................................................117
Tetracyclines...............................................................................................................................119
Mechanisms of tetracycline resistance........................................................................................119
Glycylcyclines.............................................................................................................................120
Chloramphenicol.........................................................................................................................120
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Mechanisms of chloramphenicol resistance................................................................................120
Macrolide antibiotics..................................................................................................................121
Macrolides in the narrow sense..............................................................................................121
Azalides..................................................................................................................................122
Ketolides.................................................................................................................................123
Mechanisms of macrolide resistance...........................................................................................123
Lincosamides...............................................................................................................................125
Mechanisms of lincosamide resistance.......................................................................................125
Streptogramins............................................................................................................................126
Mechanisms of streptogramin resistance....................................................................................127
Oxazolidinones............................................................................................................................128
Mechanisms of oxazolidinone resistance....................................................................................128
Fusidic acid.................................................................................................................................128
Pleuromutilines...........................................................................................................................128
Inhibitors of nucleic acid metabolism........................................................................................................129
Quinolones, fluoroquinolones.....................................................................................................129
1st generation..........................................................................................................................129
Norfloxacin.............................................................................................................................130
2nd generation..........................................................................................................................130
3rd generation..........................................................................................................................130
4th generation..........................................................................................................................131
„5th generation”.......................................................................................................................131
Mechanisms of quinolone resistance...........................................................................................131
Rifamycins...................................................................................................................................133
Mechanisms of rifamycin resistance...........................................................................................133
Drugs targeting folic acid metabolism.......................................................................................................134
Sulfonamides...............................................................................................................................134
Mechanisms of sulfonamide resistance.......................................................................................134
Trimethoprim...............................................................................................................................135
Mechanisms of trimethoprim resistance......................................................................................135
Drugs with miscellaneous mechanism of action........................................................................................136
Metronidazole.............................................................................................................................136
Nitrofurantoin.............................................................................................................................136
Methenamine...............................................................................................................................136
Mupirocin....................................................................................................................................137
Nitazoxanide................................................................................................................................137
Drugs inhibiting potential new targets.......................................................................................................137
The most important natural resistances according to pathogens................................................................138
Antituberculotic agents..................................................................................................................................139
Antituberculotic susceptibility testing........................................................................................................139
The proportion method.........................................................................................................................140
The radiometric method........................................................................................................................140
MGIT (Mycobacterium Growth Indicator Tube) method.....................................................................140
First-line antituberculotics.........................................................................................................................141
Isonicotinic acid-hydrazide (isoniazide, INH)............................................................................141
Mechanisms of INH resistance....................................................................................................142
Rifamycins...................................................................................................................................142
Pyrazinamide...............................................................................................................................143
Ethambuthol................................................................................................................................143
Streptomycin................................................................................................................................143
Second-line antituberculotics.....................................................................................................................143
Fluoroquinolones........................................................................................................................144
Paraamino-salicylic acid (PAS)..................................................................................................144
Cycloserine..................................................................................................................................144
Ethionamide, prothionamide.......................................................................................................144
Capreomycin, viomycin...............................................................................................................145
Amikacin, kanamycin, streptomycin............................................................................................145
Thioacetazone.............................................................................................................................145
Principles of antituberculotic therapy........................................................................................................146
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Drugs against leprosy................................................................................................................................146
Dapsone......................................................................................................................................146
Clofazimine.................................................................................................................................146
Rifamycins (rifampin)..................................................................................................................147
Other drugs.................................................................................................................................147
Drugs against atypical mycobacteria.........................................................................................................147
Macrolides...................................................................................................................................147
Miscellaneous drugs....................................................................................................................147
Other drugs................................................................................................................................................147
Antifungal agents...........................................................................................................................................148
Polyenes......................................................................................................................................150
Amphotericin B......................................................................................................................150
Nystatin...................................................................................................................................151
Natamycin...............................................................................................................................151
Mechanisms of resistance to polyenes.........................................................................................151
Azole antifungals.........................................................................................................................152
Imidazoles..............................................................................................................................152
Triazoles.................................................................................................................................153
Mechanisms of resistance to azole antifungals...........................................................................154
5-fluorocytosine (flucytosine)......................................................................................................155
Mechanisms of flucytosine resistance.........................................................................................155
Allylamines..................................................................................................................................156
Morpholines (amorolfine)...........................................................................................................156
Griseofulvin.................................................................................................................................156
Echinocandins.............................................................................................................................157
Drugs active against Pneumocystis jiroveczii (carinii)...................................................................158
Drugs used in microsporidiosis........................................................................................................158
Antiprotozoal drugs........................................................................................................................................159
Drugs against protozoa parasitizing body cavities.....................................................................................159
Nitroimidazoles...........................................................................................................................160
Quinacrine..................................................................................................................................160
Furazolidone...............................................................................................................................161
Paromomycin..............................................................................................................................161
Emetine........................................................................................................................................161
Iodoquinol...................................................................................................................................161
Diloxanide furoate......................................................................................................................161
Tetracyclines...............................................................................................................................162
Nitazoxanide................................................................................................................................162
Albendazole (benzimidazoles).....................................................................................................162
Other drugs.................................................................................................................................162
Antimalarial agents....................................................................................................................................162
Drugs targeting folic acid metabolism..............................................................................................164
Sulfonamides and sulfones (type 1 folic acid antagonists)..........................................................164
Diaminopyrimidines (type II folic acid antagonists)...................................................................164
Biguanides (type II folic acid antagonists)..................................................................................165
Drugs targeting mitochondria...........................................................................................................165
Naphtoquinones..........................................................................................................................165
8-aminoquinolines.......................................................................................................................166
Tafenoquine.................................................................................................................................166
Blood schizontocidal drugs..............................................................................................................167
Quinolines and their structural analogues..................................................................................167
4-aminoquinolines (type 1 blood schizontocidal drugs).........................................................167
Aminoacridines (type 1 blood schizontocidal drugs)..............................................................168
Bis-quinolines (type 1 blood schizontocidal drugs)................................................................168
Cinchona alcaloids (type 2 blood schizontocidal drugs)........................................................169
Quinoline-methanoles (type 2 blood schizontocidal drugs)....................................................169
Halofantrine (type 2 blood schizontocidal drug)....................................................................170
Lumefantrine (benflumetol) (type 2 blood schizontocidal drug)............................................170
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Artemisinin-derivatives...............................................................................................................170
Rarely used antimalarials.................................................................................................................171
Tetracyclines...............................................................................................................................171
Clindamycin................................................................................................................................171
Macrolides...................................................................................................................................171
Antimalarial drug combinations.......................................................................................................172
Treatment and chemoprophylaxis of malaria...................................................................................173
Drugs against Toxoplasma.........................................................................................................................173
Drugs against Trypanosoma spp................................................................................................................174
Diamidines (pentamidine)...........................................................................................................174
Suramin.......................................................................................................................................175
Organic arsenicals......................................................................................................................175
Eflornithine.................................................................................................................................176
Nitrofurans (Nifurtimox).............................................................................................................176
Nitroimidazoles...........................................................................................................................176
Other drugs against Trypanosoma spp.......................................................................................177
Drugs against Leishmania spp...................................................................................................................177
Organic antimony derivatives (antimonials)...............................................................................178
Amphotericin-B...........................................................................................................................179
Paromomycin (Aminosidine).......................................................................................................179
Phosphocholines.........................................................................................................................179
Azoles..........................................................................................................................................180
Diamidines..................................................................................................................................180
Allopurinol..................................................................................................................................180
Other drugs.................................................................................................................................180
Drugs against free-living amoebae............................................................................................................181
Drugs of first choice in protozoal infections..............................................................................................181
In vitro testing of the susceptibility of protozoa........................................................................................182
Anthelminthic drugs.......................................................................................................................................183
Drugs affecting the microtubular system of worms...................................................................................184
Benzimidazoles............................................................................................................................184
Drugs affecting the nervous system of the worms.....................................................................................185
Drugs acting on excitatory (acetylcholinerg) synapses.........................................................................185
Imidazolothiazoles.......................................................................................................................185
Tetrahydropyrimidines................................................................................................................186
Bephenium...................................................................................................................................186
Metrifonate..................................................................................................................................186
Drugs acting on inhibitory synapses.....................................................................................................186
Macrocyclic lactones (avermectins)............................................................................................186
Piperazine...................................................................................................................................187
Drugs affecting the carbohydrate- or energy metabolism of the worms................................................187
Niclosamide.................................................................................................................................187
Bithionol......................................................................................................................................188
Albendazole.................................................................................................................................188
Cyanine dyes...............................................................................................................................188
Drugs with other or unknown mechanism of action..............................................................................189
Diethylcarbamazine....................................................................................................................189
Praziquantel................................................................................................................................189
Oxamniquine...............................................................................................................................190
Artemisinin derivatives................................................................................................................190
Nitazoxanide................................................................................................................................190
Tribendimidine............................................................................................................................190
Spectrum of anthelminthic drugs...............................................................................................................191
Drugs of first choice in human helminthioses............................................................................................192
Anthelminthic susceptibility testing...........................................................................................................193
Drugs against ectoparasites...........................................................................................................................194
Pyrethroids..................................................................................................................................194
Lindane........................................................................................................................................195
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Ivermectin....................................................................................................................................195
Organophosphates......................................................................................................................195
Other drugs.................................................................................................................................195
Antiviral agents..............................................................................................................................................196
Resistance to antiviral agents.....................................................................................................................197
Determination of the antiviral susceptibility..............................................................................................197
Methods based on genotypic tests.........................................................................................................197
Phenotypic testing of constructs............................................................................................................198
Phenotypic methods..............................................................................................................................198
Plaque reduction assays....................................................................................................................198
Examination of dye uptake...............................................................................................................198
Examination of nucleic acid hybridization.......................................................................................199
Direct demonstration of enzymes or enzyme activities causing resistance.......................................199
Virtual phenotyping..............................................................................................................................199
Drugs active against both DNA and RNA viruses.....................................................................................201
Ribavirin......................................................................................................................................201
a-interferon.................................................................................................................................202
Drugs against DNA viruses.......................................................................................................................203
Drugs against herpesviruses..................................................................................................................203
Nucleoside analogues.......................................................................................................................203
Guanosine analogues..................................................................................................................203
Acyclovir and valacyclovir.....................................................................................................203
Mechanisms of resistance to acyclovir...................................................................................204
Penciclovir and famciclovir....................................................................................................205
Ganciclovir and valganciclovir...............................................................................................205
Other nucleoside analogues........................................................................................................206
Brivudine................................................................................................................................206
Kinase-independent antiherpesviral drugs........................................................................................206
Foscarnet....................................................................................................................................206
Cidofovir.....................................................................................................................................206
Adefovir.......................................................................................................................................207
Topically used antiherpesviral drugs................................................................................................207
Idoxuridine..................................................................................................................................207
Trifluridine..................................................................................................................................207
Docosanol...................................................................................................................................208
Fomivirsen...................................................................................................................................208
Novel investigational antiherpesviral agents....................................................................................208
Drugs against HBV...............................................................................................................................208
a-interferon.................................................................................................................................209
Lamivudine..................................................................................................................................209
Emtricitabine...............................................................................................................................209
Adefovir, tenofovir.......................................................................................................................209
Entecavir.....................................................................................................................................210
Penciclovir, famciclovir and ganciclovir....................................................................................210
Drugs under development...........................................................................................................210
Drugs against other DNA viruses..........................................................................................................211
Drugs against adenoviruses..............................................................................................................211
Drugs against papillomaviruses........................................................................................................211
Drugs against poxviruses.................................................................................................................211
Drugs against RNA viruses........................................................................................................................212
Drugs against HCV...............................................................................................................................212
Ribavirin......................................................................................................................................212
a-interferon.................................................................................................................................212
New agents..................................................................................................................................212
Drugs against picornaviruses................................................................................................................212
Drugs against influenzaviruses..............................................................................................................212
Adamantanes...............................................................................................................................212
Neuraminidase inhibitors............................................................................................................213
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