A 20-year-old female presents to the ER with complaints of fever, pelvic pain,

and some nausea and vomiting increasing over the last 2 days. She denies diarrhea

or sick contacts. She is currently sexually active with a new partner. On

examination she has a temperature of 38.9°C (102°F) and appears ill. She has

moderate bilateral lower abdominal tenderness and minimal guarding without

rebound or distention. Bowel sounds are present and normal. Pelvic exam

revealed a foul-smelling discharge through cervix with severe cervical motion

tenderness and bilateral adnexal tenderness. Cervical cultures were obtained.

Patient was begun on a quinolone antibiotic.

◆ What is the most likely diagnosis?

◆ What is the biochemical mechanism of action of the quinolone?

◆ What is the role of deoxyribonucleic acid (DNA) topoisomerases?

Summary: A 20-year-old female with history of new sexual partner, fever,

abdominal and pelvic pain, foul-smelling discharge through cervical os, and

severe cervical motion tenderness.

◆ Most likely diagnosis: Pelvic inflammatory disease

◆ Biochemical mechanism of action of quinolone: Inhibits DNA gyrase

◆ Function of topoisomerases: Enzymes that assist in formation of

superhelices and regulate the breaking and rejoining of DNA chains

CLINICAL CORRELATION

Pelvic inflammatory disease (PID) is usually an acute infection affecting the

fallopian tubes and possibly the uterus and ovaries. It is generally sexually

transmitted, caused by organisms such as Chlamydia or Neisseria gonorrhoeae

(gonorrhea). The diagnosis is made clinically based on the typical history and

physical examination. A purulent cervical discharge is highly suggestive.

Nearly all patients have cervical motion tenderness, that is, pain with motion

and palpation of the cervix. The treatment is with antibiotics. Quinolone antibiotics

have been popular in the past; however, increasing bacterial resistance,

particularly in Southeast Asia and California, has rendered these agents less

desirable. Complications of PID include infertility or ectopic pregnancy (pregnancy

in the tube) as consequence of tubal damage.

Definitions

DNA gyrase: A type II topoisomerase enzyme present in bacteria that

introduces negative supercoils into the DNA double helix in advance of

the replication fork.

Histones: Proteins containing a large number of positively charged amino

acids (lysine, arginine) that associate with DNA to form nucleosomes.

Nucleosome: Disk-shaped particles that consist of a core of histone protein

around which DNA is wrapped. They are a structural unit of chromatin.

Supercoiling: The act of DNA winding on itself as a result of unwinding

caused by replication forks.

Topoisomerase: Enzymes that control the amount of supercoiling in DNA.

Type I topoisomerases will cleave one strand of DNA to relieve supercoiling,

whereas type II topoisomerases will cleave both strands of the

DNA double helix.

DISCUSSION

The quinolones are broad-spectrum synthetic antibiotic drugs that contain

the 4-quinolone ring (Figure 10-1). The first quinolone, nalidixic acid, was

synthesized in 1962. More recently, a family of fluoroquinolones has been

produced that contain a fluorine substituent at position 6 and a carboxylic acid

moiety in the 3 position of the basic ring structure. R1, R7, and X are substituted
with different side chains for the purpose of increasing bioavailability of

the compound. A typical example of a fluoroquinolone is ciprofloxacin. The

quinolone antibiotics target bacterial DNA gyrase in many gram-negative bacteria

such as Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa,

and the like.

Supercoiling is controlled by a remarkable group of enzymes known as

topoisomerases, which alter the topology of the circular DNA but not its covalent structure. There
are two classes of topoisomerases. Type I topoisomerases

relax DNA from negative supercoils formed by the action of type II

topoisomerase by creating transient single-strand breaks in DNA without any

expense of ATP. Type II topoisomerases (also called DNA gyrases) change

DNA topology by making transient double-strand breaks in DNA and

require ATP consumption (Figure 10-3).

Figure 10-3. DNA gyrase action and quinolone inhibition.

A 48-year-old man comes to your office with a 6-day history of worsening

cough productive of green sputum. He has had fever and chills. He complains

of pain in the right midback with deep breathing or coughing. Further history

reveals that he has smoked one pack of cigarettes a day for 30 years. He has

no other significant medical history. On examination, his temperature is

38.1°C (100.5°F); his respiratory rate is 24 breaths per minute; pulse, 98 beats

per minute; blood pressure, 120/75 mm Hg; and saturation of oxygen, 96 percent

on room air by pulse oximetry. Auscultation of his lungs reveals rales in

the right lower-posterior lung field. The remainder of his examination is within

normal limits. A posterior-to-anterior (PA) and lateral chest x-ray show a right

lower-lobe infiltrate. A sputum Gram-stain reveals gram-positive cocci, and

subsequent sputum and blood culture results confirm the diagnosis of pneumonia

caused by Streptococcus pneumoniae (pneumococcus). You treat him

with a combination of amoxicillin and clavulanic acid.

◆ What is the mechanism of action of amoxicillin?

◆ What is the mechanism of action of clavulanic acid?

Summary: A 48-year-old man with pneumococcal pneumonia is being treated

with amoxicillin and clavulanic acid.

◆ Mechanism of action of amoxicillin: Inactivation of bacterial

transpeptidases and prevention of cross-linking of peptidoglycan

polymers necessary for cell-wall integrity, resulting in loss of cell-wall

rigidity and cell rupture; also inhibition of cell-wall synthesis.

◆ Mechanism of action of clavulanic acid: Irreversible inhibition of

β-lactamase.

CLINICAL CORRELATION

Penicillin is the prototype antibiotic in the β-lactam class. b-Lactam antibiotics

interfere with bacterial transpeptidases and thereby prevent the

cross-linking of peptidoglycan polymers essential for cell-wall integrity.

They do this by binding to the active site of the penicillin-binding protein (an

enzyme) that is involved in maintaining cell-wall stability. β-Lactam antibiotics

are bactericidal in growing cells, with gram-positive bacteria being particularly

susceptible. Penicillin has activity against many gram-positive

aerobic organisms, some gram-negative aerobes and anaerobic organisms. It

does not have significant activity against gram-negative rods. Amoxicillin is an

extended-spectrum penicillin with better activity against gram-negative rods

and similar activity against other organisms. Both penicillin and amoxicillin

are susceptible to b-lactamases, which cleave the β-lactam ring required for

antibacterial action. Clavulanic acid (and sulbactam and tazobactam) is structurally

similar to penicillin. It has no antimicrobial activity of its own but it

irreversibly inhibits certain β-lactamases. It frequently is given in fixed combination

with amoxicillin, thus allowing it to be used to treat β-lactamaseproducing

organisms. Penicillins can cause hypersensitivity reactions in

susceptible persons. Approximately 5–10 percent of penicillin-allergic persons

will have a cross-sensitivity to cephalosporin drugs as well. Penicillins also

have gastrointestinal (GI) side effects, and the addition of clavulanic acid significantly

increases the incidence of diarrhea.

Definitions

Chemotherapy: Therapeutic use of chemical agents that selectively act on

microbes and cancer.

Plasmids: Extrachromosomal genetic elements that may be transferred

between bacteria.

DISCUSSION

Class

The basic principles for the selection of antibacterial therapy include consideration

of factors such as the likelihood that the infection is bacterial and the

identification of the likely infecting organism to support a rational selection of

an antibiotic. Consideration of host and drug factors that could influence antibiotic

selection include identification of the site of infection, which will influence

the selection of the antibiotic and its route of administration; recognition of

concomitant diseases such as AIDS; recognition of the likelihood of drug allergies;

recognition of hepatic or renal dysfunction that could alter antibiotic clearance;

and recognition of drug toxicity, drug-drug interactions, drug resistance,

the patient’s age or pregnancy or maternal status; and drug cost.

Antibacterial agents, which target specific components of microorganisms

that are unique or more essential to their function than they are to humans, are

classified according to their mechanisms of action. The component targets

include enzymes necessary for bacterial cell-wall synthesis, the bacterial

ribosome, and enzymes necessary for nucleotide synthesis and deoxyribonucleic

acid (DNA) replication.

Resistance of pathogens to antibacterial and other chemotherapeutic agents

may be the result of a natural resistance or may be acquired. In either case, it

occurs through mutation, adaptation, or gene transfer. The mechanism of resistance

for any antibacterial agent varies, but is a result of either changes in uptake

of drug into, or its removal from, the bacterial cell, or to changes in the bacterial

cell target site of the drug from a gene mutation. Multiple drug resistance

is also a major impediment to antibacterial therapy and may be chromosomal

or plasmid mediated, where genetic elements from resistant bacteria that code

for enzymes that inactivate antibacterial agents are transferred to nonresistant

bacteria. The emergence of drug resistance is to a large degree the result of the

widespread and often unnecessary or inappropriate use of antibiotics in humans.

The penicillins (see above) include natural penicillins, penicillins that are

resistant to staphylococcal β-lactamase, and extended-spectrum penicillins

(Table 46-1).

The cephalosporins are classified as first to fourth generation, according to

their antibacterial spectrum (Table 46-2).

Table 46-3 lists these and other selected antimicrobial agents. Aztreonam,

which is relatively β-lactamase resistant, is the only available monobactam.

Table 46-1
PARTIAL LISTING OF PENICILLINS
Natural
Penicillin G (prototype)
Penicillin V
b-Lactamase Resistant
Nafcillin
Oxacillin
Cloxacillin
Dicloxacillin
Table 46-2
SELECTED LISTING OF CEPHALOSPORINS
REPRESENTATIVE
CEPHALOSPORINS (route)
First generation Active against gram-positive cocci, including
• Cefazolin (IV) staphylococci, pneumococci, and streptococci.
• Cephalexin (PO) They are particularly good for soft tissue and
• Cefadroxil (PO) skin infection
Second generation These agents have marked differences in their
• Cefuroxime (IV) oral spectrum of activity. In general, they are active
form is cefuroxime axetil against certain aerobic gram-negative bacteria in
• Cefotoxin (IV) addition to activity against many gram-positive
• Cefotetan (IV) organisms sensitive to first-generation
cephalosporins. Certain agents are active against
Haemophilus influenza (e.g., cefuroxime),
whereas others are active against Bacteroides
fragilis (e.g., cefotoxin)
Third generation Expanded aerobic gram-negative spectrum.
• Cefotaxime (IV) Cross the blood-brain barrier. Useful to treat
• Ceftazidime (IV) bacterial strains resistant to other drugs
• Ceftriaxone (IV)
Fourth generation Generally similar activity to third-generation
• Cefepime (IV) cephalosporins but more resistance to -lactamases
Extended-Spectrum
Aminopenicillins
Ampicillin
Amoxicillin
Ureidopenicillins
Mezlocillin
Piperacillin
Carboxypenicillin
Ticarcillin

Table 46-3

PARTIAL LISTING OF ANTIMICROBIAL AGENTS

ANTIBACTERIAL MECHANISM

AGENTS OF ACTION

b-Lactam antibiotics

Inhibit synthesis of the bacterial cell wall

hypersensitivity with rare potential for anaphylactic shock

Penicillins

Cephalosporins

Monobactams Cephalosporins: may cause

• Aztreonam (p) local irritation and pain from

Carbapenems IM injection. Those with a

• Imipenem (p) methylthiotetrazole group,

• Meropenem (p) e.g., cefotetan, may cause

• Ertapenem (p) hypoprothrombinemia and

Vancomycin (o,p) bleeding disorders

Aztreonam: occasionally

may cause skin rashes

Carbapenems: may cause GI

discomfort and skin rashes

and seizures in patients with

renal dysfunction (particularly

imipenem)

Vancomycin: relatively nontoxic.

Fever, chills, and

infusion-related flushing

(“red-man” syndrome) are

encountered. Ototoxicity is a

rare effect

Chloramphenicol Bind to bacterial Chloramphenicol:

Tetracyclines ribosomes to inhibit GI disturbances,

• Tetracycline (o,p) protein synthesis reversible suppression of

• Oxytetracycline (o,p) bone marrow, rarely

• Doxycycline (o,p) aplastic anemia

• Methacycline (o) Tetracyclines: GI

• Minocycline (o,p) disturbances and bacterial

Macrolides overgrowth, teeth and bone

• Erythromycin (o,p) deformation in children

• Clarithromycin (o) Erythromycin and

• Azithromycin (o) clarithromycin: severe GI

Ketolides disturbances, hypersensitivity,

• Telithromycin (o) hepatic P450 inhibition.

Oxazolidinones Telithromycin: hepatic

• Linezolid (o,p) P450 inhibition

Aminoglycosides Linezolid: reversible

• Streptomycin (p) thrombocytopenia

• Neomycin (o) Aminoglycosides: ototoxicity

• Amikacin (p) and nephrotoxicity