for mammals. Thus, the drug can be used against bacteria and protozoa at concentrations that do not harm humans. This example of effi cacy is based on the relative insensitivity of the host compared with bacterial targets. In another example, both host cells and bacteria aresensitive to tetracycline. However, unlike mammalian cells, bacteria concentrate the antibiotic. As a result, tetracycline is effective against even intracellular organisms (e.g., chlamydiae). The armamentarium of antimicrobials includes drugs that affect the synthesis or function of every class of microbial macromolecules. Extreme selectivity is achieved when the biochemical target is absent in the host cells. The best examples are the -lactam antibiotics (e.g., penicillin), which affect the biosynthesis of the murein layer of the bacterial cell wall (see Chapter 3). No comparable structure exists in mammalian cells, which are therefore totally insensitive to the action of these antibiotics. Nonetheless, even -lactams can have undesirable side effects. Some individuals cannot take them because they have a strong allergic reaction. Also, administration of broadspectrum -lactams can result in the destruction of the normal intestinal microbiota. This effect can lead to colitis, overgrowth by fungi, and other complications. Even a nearly perfect antibiotic comes with a price. HOW DO MICROBES CIRCUMVENT THE ACTION OF ANTIBIOTICS? The destructive power of antibiotics is so pervasive that within a few years of their introduction, resistant organisms can supplant susceptible ones. At what point in the action of antibiotics does resistance come into play? The action of antimicrobial drugs can be broken into a sequence of three steps: First, the drugs must associate with the bacteria and penetrate their envelope. Second, they must be transported to an intracellular site of action. Third, they must bind to their specifi c biochemical target. Resistance to drugs can occur at each step. Microorganisms, like sophisticated biochemists, have developed a multitude of ways to become resistant. Resistance poses a serious problem when it arises in a pathogenic microbe capable of causing damage to human hosts. Following are the clinically relevant mechanisms of resistance: Synthesis of enzymes that break down the drug molecule Chemical modifi cation of the drug that interferes with its function Prevention of access to the target site by inhibiting uptake Prevention of access to the target site by increasing export of the drug from the microbial cell Modifi cation of the target site All these mechanisms have been recognized in clinical pathogens, but the most common is the last one. Some of the examples introduced in Chapter 3 are treated more fully in the following paragraphs. A more extensive list of mechanisms of antibacterial resistance is shown in Table 5-1. b-Lactams and Enzymes that Inactivate Them Chapter 3 summarized the effects of penicillins, cephalosporins, and carbapenems on cell wall formation and their consequences for bacterial survival. This group of drugs is large, and for various