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Some strains of previously susceptible bacteria, such as Staphylococcus, have developed a specific resistance to the naturally occurring penicillins; these bacteria either produce lactamase (penicillinase), an enzyme that disrupts the internal structure of penicillin and thus destroys the antimicrobial action of the drug, or they lack cell wall receptors for penicillin, greatly reducing the ability of the drug to enter bacterial cells. This has led to the production of the penicillinase-resistant penicillins. Penicillin is used in the treatment of throat infections, meningitis, syphilis, and various other infections. The chief side effects of penicillin are hypersensitivity reactions, including skin rash, hives, swelling, and anaphylaxis, or allergic shock. The more serious reactions are uncommon. Milder symptoms may be treated with corticosteroids but usually are prevented by switching to alternative antibiotics. Anaphylactic shock, which can occur in previously sensitized individuals within seconds or minutes, may require immediate administration of epinephrine. Antibiotics are specific chemical substances derived from or produced by living organisms that are capable of inhibiting the life processes of other organisms. The first antibiotics were isolated from microorganisms but some are now obtained from higher plants and animals. Over 3,000 antibiotics have been identified but only a few dozen are used in medicine. Antibiotics are the most widely prescribed class of drugs comprising 12% of the prescriptions in the United States. The penicillin was the first antibiotics discovered as natural products from the mold Penicillium. In 1928, Sir Alexander Fleming, professor of bacteriology at St. Mary's Hospital in London, was culturing Staphylococcus aureus. He noticed zones of inhibition where mold spores were growing. He named the mold Penicillium rubrum. It was determined that a secretion of the mold was effective against Gram-positive bacteria. Penicillin as well as cephalosporins are called beta-lactam antibiotics and are characterized by three fundamental structural requirements: the fused beta-lactam structure (shown in the blue and red rings, a free carboxyl acid group (shown in red bottom right), and one or more substituted amino acid side chains (shown in black). The lactam structure can also be viewed as the covalent bonding of pieces of two amino acids - cysteine (blue) and valine (red). Penicillin-G where R = an ethyl pheny group, is the most potent of all penicillin derivatives. It has several shortcomings and is effective only against gram-positive bacteria. It may be broken down in the stomach by gastric acids and is poorly and irregularly absorbed into the blood stream. In addition many disease producing staphylococci are able to produce an enzyme capable of inactivating penicillin-G. Various semisynthetic derivatives have been produced which overcome these shortcomings. Powerful electron-attracting groups attached to the amino acid side chain such as in phenethicillin prevent acid attack. A bulky group attached to the amino acid side chain provides steric hindrance which interfers with the enzyme attachment which would deactivate the pencillins i.e. methicillin. Refer to Table 2 for the structures.
Finally if the polar character is increased as in ampicillin or carbenicillin, there is a greater activiity against Gram-negative bacteria.
TABLE 2
Adverse Effects
Common adverse drug reactions ( 1% of patients) associated with use of the penicillins include diarrhoea, hypersensitivity, nausea, rash, neurotoxicity, urticaria, and superinfection (includingcandidiasis). Infrequent adverse effects (0.11% of patients) include fever, vomiting, erythema, dermatitis, angioedema, seizures (especially in people with epilepsy), and pseudomembranous colitis. Get emergency medical help if a patient is having any of these signs of an allergic reaction to penicillin V: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. diarrhea that is watery or bloody;
Fever, chills, body aches, flu symptoms; Easy bruising or bleeding, unusual weakness; Urinating less than usual or not at all; Severe skin rash, itching, or peeling; Agitation, confusion, unusual thoughts or behavior; or Seizure (black-out or convulsions).
Less serious penicillin V side effects are more likely to occur, such as:
Nausea, vomiting, stomach pain; Vaginal itching or discharge; Headache; Swollen, black, or "hairy" tongue; or Thrush (white patches or inside your mouth or throat).
It is estimated that between 300-500 people die each year from penicillin-induced anaphylaxis, a severe allergic shock reaction to penicillin. In afflicted individuals, the betalactam ring binds to serum proteins, initiating an IgE-mediated inflammatory response.
Important Notes
Penicillin cannot be used by a patient that is allergic to penicillin V or to any other penicillin antibiotic, such as amoxicillin (Amoxil), ampicillin (Omnipen, Principen), carbenicillin (Geocillin), dicloxacillin (Dycill, Dynapen), or oxacillin (Bactocill). Before using penicillin V, a patient must tell the doctor if he is allergic to cephalosporins such as Ceclor, Ceftin, Duricef, Keflex, and others, or if he has asthma, kidney disease, a bleeding or blood clotting disorder, a history of diarrhea caused by taking antibiotics, or a history of any type of allergy. Penicillin V can make birth control pills less effective, which may result in pregnancy. Before taking this medicine, a patient must tell her doctor if she uses birth control pills. One must take penicillin V for the entire length of time prescribed by her doctor. Symptoms may get better before the infection is completely treated. Penicillin V will not treat a viral infection such as the common cold or flu. This medication must not be given to another person, even if they have the same symptoms that you have. Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. This medication must not be taken if a patient is allergic to penicillin V or to any other penicillin antibiotic, such as:
Amoxicillin (Amoxil, Amoxicot, Biomox, Dispermox, Trimox); Ampicillin (Omnipen, Principen); Carbenicillin (Geocillin); Dicloxacillin (Dycill, Dynapen); or Oxacillin (Bactocill).
New users of penicillin must be assessed by a doctor if you are allergic to any drugs (especially cephalosporins such as Ceclor, Ceftin, Duricef, Keflex, and others), or if you have:
Asthma; Kidney disease; A bleeding or blood clotting disorder; A history of diarrhea caused by taking antibiotics; or A history of any type of allergy.
FDA pregnancy category B. Penicillin V is not expected to be harmful to an unborn baby. A pregnant patient may tell her doctor if she is pregnant or plan to become pregnant during treatment. Penicillin V can make birth control pills less effective, which may result in pregnancy. Penicillin V can pass into breast milk and may harm a nursing baby. This medication cant be used without a patient telling her doctor if she is breast-feeding a baby.
Mechanism of Action
Our immune system is usually enough to destroy harmful bacteria, as we have white blood cells that attack them before they multiply. Even if symptoms do occur, our immune system can usually fight off the infection itself. Nevertheless there are instances where it is all too much for our bodies, and they need help which is where antibiotics come in. Bacteria constantly remodel their peptidoglycan cell walls, simultaneously building and breaking down portions of the cell wall as they grow and divide. -Lactam antibiotics inhibit the formation of peptidoglycan cross-links in the bacterial cell wall; this is achieved through binding of the four-membered -lactam ring of penicillin to theenzyme DD-transpeptidase. As a consequence, DD-transpeptidase cannot catalyzeformation of these cross-links, and an imbalance between cell wall production and degradation develops, causing the cell to rapidly die. The enzymes that hydrolyze the peptidoglycan cross-links continue to function, even while those that form such cross-links do not. This weakens the cell wall of the bacterium, and osmotic pressure continues to riseeventually causing cell death (cytolysis). In addition, the build-up of peptidoglycan precursors triggers the activation of bacterial cell wall hydrolases and autolysins, which further digest the cell wall's peptidoglycans. The small size of the penicillins increases their potency, by allowing them to penetrate the entire depth of the cell wall. This is in contrast to theglycopeptide antibiotics vancomycin and teicoplanin, which are both much larger than the penicillins.
Gram-positive bacteria are called protoplasts when they lose their cell walls. Gramnegative bacteria do not lose their cell walls completely and are calledspheroplasts after treatment with penicillin. Penicillin shows a synergistic effect with aminoglycosides, since the inhibition of peptidoglycan synthesis allows aminoglycosides to penetrate the bacterial cell wall more easily, allowing their disruption of bacterial protein synthesis within the cell. This results in a lowered MBC for susceptible organisms. Penicillins, like other -lactam antibiotics, block not only the division of bacteria, including cyanobacteria, but also the division of cyanelles, the photosyntheticorganelles of the glaucophytes, and the division of chloroplasts of bryophytes. In contrast, they have no effect on the plastids of the highly developed vascular plants. This supports the endosymbiotic theory of the evolution of plastid division in land plants.
Bacteria that attempt to grow and divide in the presence of penicillin fail to do so, and instead end up shedding their cell walls.
Gram-positive bacteria possess a thick cell wall composed of a cellulose-like structural sugar polymer covalently bound to short peptide units in layers.The polysaccharide portion of the peptidoglycan structure is made of repeating units of N-acetylglucosamine linked b-1,4 to Nacetylmuramic acid (NAG-NAM). The peptide varies, but begins with L-Ala and ends with D-Ala. In the middle is a dibasic amino acid, diaminopimelate (DAP). DAP (orange) provides a linkage to the D-Ala (gray) residue on an adjacent peptide. The bacterial cell wall synthesis is completed when a cross link between two peptide chains attached to polysaccharide backbones is formed.The cross linking is catalyzed by the enzyme transpeptidase. First the terminal alanine from each peptide is hydrolyzed and secondly one alanine is joined to lysine through an amide bond. Penicillin binds at the active site of the transpeptidase enzyme that cross-links the peptidoglycan strands. It does this by mimicking the D-alanyl-D-alanine residues that would normally bind to this site. Penicillin irreversibly inhibits the enzyme transpeptidase by reacting with a serine residue in the transpeptidase. This reaction is irreversible and so the growth of the bacterial cell wall is inhibited. Since mammal cells do not have the same type of cell walls, penicillin specifically inhibits only bacterial cell wall synthesis.
Penicillin and other -lactam antibiotics act by inhibiting penicillin-binding proteins, which normally catalyze cross-linking of bacterial cell walls
Cephalosphorins
Cephalosporins are the second major group of beta-lactam antibiotics. They differ from penicillins by having the beta-lactam ring as a 6 member ring. The other difference, which is more significant from a medicinal chemistry stand point, is the existence of a functional group (R) at position 3 of the fused ring system. This now allows for molecular variations to effect changes in properties by diversifying the groups at position 3. The first member of the newer series of beta-lactams was isolated in 1956 from extracts of Cephalosporium acremonium, a sewer fungus. Like penicillin, cephalosporins are valuable because of their low toxicity and their broad spectrum of action against various diseases. In this way, cephalosporin is very similar to penicillin. Cephalosporins are one of the most widely used antibiotics, and economically speaking, has about 29% of the antibiotic market. The cephalosporins are possibly the single most important group of antibiotics today and are equal in importance to penicillin. The structure and mode of action of the cephalosporins are similar to that of penicillin. They affect bacterial growth by inhibiting cell wall synthesis, in Gram-positive and negative bacteria. Some brand names include: cefachlor, cefadroxil, cefoxitin, ceftriaxone.
Structure
The term "penam" is used to describe the common core skeleton of a member of the penicillins. This core has the molecular formula R-C9H11N2O4S, where R is the variable side chain that differentiates the penicillins from one another. The penam core has a molecular weight of 243 g/mol, with larger penicillins having molecular weights near 450for example, cloxacillin has a molecular weight of 436 g/mol. The key structural feature of the penicillins is the four-membered -lactam ring; this structural moiety is essential for penicillin's antibacterial activity. The -lactam ring is itself fused to a five-membered thiazolidine ring. The fusion of these two rings causes the -lactam ring to be more reactive than monocyclic -lactams because the two fused rings distort the -lactam amide bond and therefore remove the resonance stabilisation normally found in these chemical bonds.
Chemical structure of Penicillin G. The sulfur and nitrogen of the five-membered thiazolidine ring are shown in yellow and blue respectively. The image shows that the thiazolidine ring and fused four-membered -lactam are not in the same plane.
Biosynthesis
The first step is the condensation of three amino acidsL--aminoadipic acid, Lcysteine, L-valine into a tripeptide. Before condensing into the tripeptide, the amino acid Lvaline must undergo epimerization to become D-valine. The condensed tripeptide is named -(L--aminoadipyl)-L-cysteine-D-valine (ACV). The condensation reaction and epimerization are both catalyzed by the enzyme -(L--aminoadipyl)-L-cysteine-D-valine synthetase (ACVS), a nonribosomal peptide synthetase or NRPS. The second step in the biosynthesis of penicillin G is the oxidative conversion of linear ACV into the bicyclic intermediate isopenicillin N byisopenicillin N synthase (IPNS), which is encoded by the gene pcbC.[7][8] Isopenicillin N is a very weak intermediate, because it does not show strong antibiotic activity. The final step is a transamidation by isopenicillin N N-acyltransferase, in which the aminoadipyl side-chain of isopenicillin N is removed and exchanged for a phenylacetyl sidechain. This reaction is encoded by the gene penDE, which is unique in the process of obtaining penicillins.
Production
Penicillin is a secondary metabolite of certain species of Penicillium and is produced when growth of the fungus is inhibited by stress. It is not produced during active growth. Production is also limited by feedback in the synthesis pathway of penicillin. -ketoglutarate + AcCoA homocitrate L--aminoadipic acid L-lysine + lactam The by-product, L-lysine, inhibits the production of homocitrate, so the presence of exogenous lysine should be avoided in penicillin production. The Penicillium cells are grown using a technique called fed-batch culture, in which the cells are constantly subject to stress, which is required for induction of penicillin production. The
available carbon sources are also important: Glucose inhibits penicillin production, whereas lactose does not. The pH and the levels of nitrogen, lysine, phosphate, and oxygen of the batches must also be carefully controlled. The biotechnological method of directed evolution has been applied to produce by mutation a large number of Penicillium strains. These techniques include error-prone PCR, DNA shuffling, ITCHY, and strand-overlap PCR. Semisynthetic penicillins are prepared starting from the penicillin nucleus 6-APA.
History of Penicillin
Alexander Flemings Discovery of Penicillin
Penicillin heralded the dawn of the antibiotic age. Before its introduction there was no effective treatment for infections such as pneumonia, gonorrhea or rheumatic fever. Hospitals were full of people with blood poisoning contracted from a cut or a scratch, and doctors could do little for them but wait and hope. Antibiotics are compounds produced by bacteria and fungi which are capable of killing, or inhibiting, competing microbial species. This phenomenon has long been known; it may explain why the ancient Egyptians had the practice of applying a poultice of moldy bread to infected wounds. But it was not until 1928 that penicillin, the first true antibiotic, was discovered by Alexander Fleming, Professor of Bacteriology at St. Mary's Hospital in London. Returning from holiday on September 3, 1928, Fleming began to sort through petri dishes containing colonies of Staphylococcus, bacteria that cause boils, sore throats and abscesses. He noticed something unusual on one dish. It was dotted with colonies, save for one area where a blob of mold was growing. The zone immediately around the moldlater identified as a rare strain of Penicillium notatumwas clear, as if the mold had secreted something that inhibited bacterial growth. Fleming found that his "mold juice" was capable of killing a wide range of harmful bacteria, such as streptococcus, meningococcus and the diphtheria bacillus. He then set his assistants, Stuart Craddock and Frederick Ridley, the difficult task of isolating pure penicillin from the mold juice. It proved to be very unstable, and they were only able to prepare solutions of crude material to work with. Fleming published his findings in the British Journal of Experimental Pathology in June 1929, with only a passing reference to penicillin's potential therapeutic benefits. At this stage it looked as if its main application would be in isolating penicillin-insensitive bacteria from penicillin-sensitive bacteria in a mixed culture. This at least was of practical benefit to bacteriologists, and kept interest in penicillin going. Others, including Harold Raistrick, Professor of Biochemistry at the London School of Hygiene and Tropical Medicine, tried to purify penicillin but failed.
Yale physiologist John Fulton helped to put his British colleagues in touch with individuals who might be able to assist them in their goal. They were referred to Robert Thom of the Department of Agriculture, a foremost mycologist and authority on the Penicillium mold, and eventually to the Department's Northern Regional Research Laboratory (NRRL) in Peoria, Illinois, because of the expertise of its Fermentation Division. This contact proved to be crucial to the success of the project, as the NRRL was a key contributor of innovations that made largescale production of penicillin possible.
Florey's arrival and Pfizer seemed on the verge of investigating the drug as well. At this time, however, the promise of penicillin was still based on only limited clinical trials. Florey next visited his old friend Alfred Newton Richards, then vice president for medical affairs at the University of Pennsylvania. More importantly, Richards was chair of the Committee on Medical Research (CMR) of the Office of Scientific Research and Development (OSRD). The OSRD had been created in June, 1941, to assure that adequate attention was given to research on scientific and medical problems relating to national defense. Richards had great respect for Florey and trusted his judgment about the potential value of penicillin. He approached the four drug firms that Florey indicated had shown some interest in the drug (Merck, Squibb, Lilly and Pfizer) and informed them that they would be serving the national interest if they undertook penicillin production and that there might be support from the federal government. Richards convened a meeting in Washington, D.C., on October 8, 1941, to exchange information on company and government research and to plan a collaborative research program to expedite penicillin production. In addition to representatives of the CMR, the National Research Council and the U.S. Department of Agriculture, participants included research directors Randolph T. Major of Merck; George A. Harrop of the Squibb Institute for Medical Research; Jasper Kane of Pfizer; and Y. SubbaRow of Lederle. The next CMR penicillin conference, held in New York in December, ten days after Pearl Harbor and U.S. entry into the Second World War, was more decisive. At this meeting, which was attended by the heads of Merck, Squibb, Pfizer and Lederle, as well as the company research directors, Robert Coghill's report on the success at the NRRL with corn steep liquor was encouraging to the industry leaders present. As Coghill later recalled, George W. Merck, who had been pessimistic about the possibility of producing adequate quantities of penicillin given the constraints of available fermentation techniques and yields,"...immediately spoke up, saying that if these results could be confirmed in their laboratories, it was possible to produce the kilo of material for Florey, and industry would do it!". It was agreed that although the companies would pursue their research activities independently, they would keep the CMR informed of developments, and the Committee could make the information more widely available (with the permission of the company involved) if that were deemed in the public interest. Although there was some concern that investments in fermentation processes might be wasted if a commercially-viable synthesis of penicillin were developed, other companies also began to show an interest in the drug. Some firms worked out collaborative agreements of their own (e.g., Merck and Squibb in February 1942, joined by Pfizer in September). Merck's pilot plant continued to produce several hundred liters of penicillin culture per week using both flasks and tray, and in December, Heatley joined the Merck research staff for several months, where he introduced the Oxford cup plate method of penicillin assay, which soon became a standard method industry-wide. By March 1942 enough penicillin had been produced under OSRD auspices to treat the first patient (Mrs. Ann Miller, in New Haven, Connecticut); a further ten cases were treated by June 1942, all with penicillin supplied by Merck & Co., Inc.
top priority on construction materials and other supplies necessary to meet the production goals. The WPB controlled the disposition of all of the penicillin produced. One of the major goals was to have an adequate supply of the drug on hand for the proposed D-Day invasion of Europe. Feelings of wartime patriotism greatly stimulated work on penicillin in the United Kingdom and the United States. For example, Albert Elder wrote to manufacturers in 1943: "You are urged to impress upon every worker in your plant that penicillin produced today will be saving the life of someone in a few days or curing the disease of someone now incapacitated. Put up slogans in your plant! Place notices in pay envelopes! Create an enthusiasm for the job down to the lowest worker in your plant." As publicity concerning this new "miracle drug" began to reach the public, the demand for penicillin increased. But supplies at first were limited, and priority was given to military use. Dr. Chester Keefer of Boston, Chairman of the National Research Council's Committee on Chemotherapy, had the unenviable task of rationing supplies of the drug for civilian use. Keefer had to restrict the use of the drug to cases where other methods of treatment had failed. Part of his job was also to collect detailed clinical information about the use of the drug so that a fuller understanding of its potential and limitations could be developed. Not surprisingly, Keefer was besieged with pleas for penicillin. A newspaper account in the New York Herald Tribune for October 17, 1943, stated: "Many laymen - husbands, wives, parents, brothers, sisters, friends beg Dr. Keefer for penicillin. In every case the petitioner is told to arrange that a full dossier on the patient's condition be sent by the doctor in charge. When this is received, the decision is made on a medical, not an emotional basis." Fortunately, penicillin production began to increase dramatically by early 1944. Production of the drug in the United States jumped from 21 billion units in 1943, to 1,663 billion units in 1944, to more than 6.8 trillion units in 1945, and manufacturing techniques had changed in scale and sophistication from one-liter flasks with less than 1% yield to 10,000-gallon tanks at 80-90% yield. The American government was eventually able to remove all restrictions on its availability, and as of March 15, 1945, penicillin was distributed through the usual channels and was available to the consumer in his or her corner pharmacy. By 1949, the annual production of penicillin in the United States was 133,229 billion units, and the price had dropped from twenty dollars per 100,000 units in 1943 to less than ten cents. Most British companies moved over to the deep tank fermentation production of penicillin, pioneered in the United States, after the end of the war to meet civilian needs. In the United Kingdom, penicillin first went on sale to the general public, as a prescription only drug, on June 1, 1946. In Britain, Chain and Abraham continued to work on the structure of the penicillin molecule, aided by the X-ray crystallographic work of Dorothy Hodgkin, also at Oxford. The unique feature of the structure, which was finally established in 1945, is the four-membered highly labile beta-lactam ring, fused to a thiazolidine ring. In the same year Alexander Fleming, Howard Florey, and Ernst Chain were awarded the Nobel Prize for their penicillin research.
The co-operative efforts of American chemists, chemical engineers, microbiologists, mycologists, government agencies, and chemical and pharmaceutical manufacturers were equal to the challenge posed by Howard Florey and Norman Heatley in 1941. As Florey observed in 1949, "too high a tribute cannot be paid to the enterprise and energy with which the American manufacturing firms tackled the large-scale production of the drug. Had it not been for their efforts there would certainly not have been sufficient penicillin by D-Day in Normandy in 1944 to treat all severe casualties, both British and American."