Aminoglycosides

Aminoglycosides
(Aminocyclitols)

These are group of natural and semisynthetic antibiotics which contain aminosugars in glycosidic linkage. These are mostly bactericidal drugs that share chemical, antimicrobial, pharmacologic, and toxic characteristics.

Classes

•         Narrow-Spectrum Aminoglycosides

            Included in this group are streptomycin and dihydrostreptomycin, which are mainly active against aerobic, gram-negative bacteria.

•         Expanded-Spectrum Aminoglycosides

            Neomycin, framycetin (neomycin B), paromomycin (aminosidine), and kanamycin have broader spectra than streptomycin that often include several gram-positive as well as many gram-negative aerobic bacteria.

•         Broad spectrum Aminoglycosides  

            Gentamicin, tobramycin, amikacin (synthesized from kanamycin), sisomicin, and netilmicin are aminoglycosides with extended spectra that include Pseudomonas aeruginosa.

•         Miscellaneous Aminoglycoside Antibiotics

            The chemical structure of apramycin differs somewhat from that of the typical aminoglycosides but is similar enough to be included in this class. The structure of spectinomycin is unusual, but it is fairly comparable to other aminocyclitols with regard to its mechanism of action and antibacterial spectrum.

SOURCES

Drug               Source

Streptomycin   Streptomyces griseus

Neomycin        S. fradiae

Kanamycin      S. kanamyceticus

Gentamicin      Micromonospora purpurea

Tobramycin     S. tenebrarius

Amikacin         Semisynthetic derivative of kanamycin

Sisomicin         Micromonospora inyoensis

Netilmicin       Semisynthetic derivative of sisomicin

Framycetin      S. lavendulae

General Properties

Chemically, the aminoglycoside antibiotics are characterized by an  aminocyclitol group, with aminosugars attached to the aminocyclitol ring in  glycosidic linkage. Because of minor differences in the position of substitutions  on the molecules, there may be several forms of a single amino-glycoside. For  example, gentamicin is a complex of gentamicins C₁ and C₂, and neomycin is a  mixture of neomycins B and C and fradiomycin.

            The amino groups contribute to  the basic nature of this class of antibiotics, and  the hydroxyl groups on the sugar moieties to high aqueous solubility and  poor  lipid solubility. If these hydroxyl groups are removed (eg, tobramycin),  antibiotic activity is markedly  increased.

            Differences in the substitutions on the basic ring structures within the various  aminoglycosides account for the relatively minor differences in  antimicrobial  spectra, patterns of resistance, and toxicities.

            Aminoglycosides are typically quite stable. When the water solubility of an aminoglycoside is marginal, it is usually the sulfate salt that is used for PO or Parenteral administration.

Common properties of Aminoglycosides

•         All are used as sulphate salts that are highly water soluble and the solutions are stable.

•         None is absorbed after oral admn., as they are polycations.

•         None penetrate the brain or CSF.

•         All are rapidly excreted unchanged through normal kidney by glomerular filtration.

•         They are exclusively used in the Rx of G – ve bacterial infections.

•         All act by interference with protein synthesis in succeptible bacteria.

•         They are bactericidal and more active in alkaline pH.

•         Partial cross resistance may be seen among them.

•         They have relatively narrow margin of safety.

•         All share common toxicities.

Antimicrobial Activity

Mode of Action

•         Aminoglycosides are more effective against rapidly multiplying organisms, and they affect and ultimately destroy bacteria by several mechanisms. They need only a short contact with bacteria to kill them. Their main site of action is the membrane-associated bacterial ribosome through which they interfere with protein synthesis. To reach the ribosome, they must first cross the lipopolysaccharide (LPS) covering (gram-negative organisms), the bacterial cell wall, and finally the cell membrane. Because of the polarity of these compounds, a specialized active transport process is required.

•         The first concentration-dependent step requires binding of the cationic aminoglycoside to anionic components in the cell membrane. The subsequent steps are energy-dependent and involve the transport of the polar, highly charged cationic aminoglycoside across the cytoplasmic membrane, followed by interaction with the ribosomes. The driving force for this transfer is probably the membrane potential. These processes are much more efficient if the energy used is aerobically generated. The efficacy of the aminoglycosides is markedly curtailed in an anaerobic environment.

Several features of these mechanisms are of clinical significance:

•         1) The anti-bacterial activity of the aminoglycosides depends on an effective concentration of antibiotic outside the cell.

•         2) Anaerobic bacteria and induced mutants are generally resistant because they lack appropriate transport systems.

•         3) With low oxygen tension, as in hypoxic tissues, transfer into bacteria is diminished.

•         4) Divalent cations (eg, calcium and magnesium) located in the LPS, cell wall, or membrane can interfere with transport into bacteria because they can combine with the specific anionic sites and exclude the cationic aminoglycosides.

•         5) Passive movement of aminoglycosides across bacterial cell membranes is facilitated by an alkaline pH; a low pH may increase membrane resistance more than 100-fold.

•         6) Changes in osmolality also can alter the uptake of aminoglycosides.

•         7) Some aminoglycosides are transported more efficiently than others, and thus tend to have greater antibacterial activity.

•         8) Synergism is common when aminoglycosides and β-lactam antibiotics (penicillins and cephalosporins) are used in combination. The cell-wall injury induced by the β-lactam compounds allows increased uptake of the aminoglycoside by the bacteria because of easier accessibility to the bacterial cell membrane.

•         The intracellular site of action of the aminoglycosides is the ribosome, which is irreversibly bound by aminoglycosides, particularly at the 30 S but also the 50 S subunits. Variability occurs between aminoglycosides with respect to their affinity and degree of binding. The number of steps in protein synthesis that are affected also varies. Spectinomycin cannot induce misreading of the mRNA and often is not bactericidal, in contrast to the other bactericidal members. However, at low concentrations, all aminoglycosides may be only bacteriostatic.

•         A cell-membrane effect also occurs with aminoglycosides. The functional integrity of the bacterial cell membrane is lost during the late phase of the transport process, and high concentrations of aminoglycosides may cause nonspecific membrane toxicity, even to the point of bacterial cell lysis.

•         Efficacy of aminoglycosides is enhanced if peak plasma or tissue drug concentrations exceed MIC by 10–12 times. Once-daily dosing has been used to enhance both efficacy and safety.

•         The intracellular site of action of the aminoglycosides is the ribosome, which is irreversibly bound by aminoglycosides, particularly at the 30 S but also the 50 S subunits. Variability occurs between aminoglycosides with respect to their affinity and degree of binding. The number of steps in protein synthesis that are affected also varies. Spectinomycin cannot induce misreading of the mRNA and often is not bactericidal, in contrast to the other bactericidal members. However, at low concentrations, all aminoglycosides may be only bacteriostatic.

•         A cell-membrane effect also occurs with aminoglycosides. The functional integrity of the bacterial cell membrane is lost during the late phase of the transport process, and high concentrations of aminoglycosides may cause nonspecific membrane toxicity, even to the point of bacterial cell lysis.

•         Efficacy of aminoglycosides is enhanced if peak plasma or tissue drug concentrations exceed MIC by 10–12 times. Once-daily dosing has been used to enhance both efficacy and safety.

Bacterial Resistance

•         Several mechanisms of resistance to the aminoglycoside antibiotics have been described. These may be plasmid or chromosomally mediated.

•         Impaired transport across the cell membrane is an inherent mechanism of nonplasmid-mediated resistance that occurs in anaerobic bacteria (eg, Bacteroides fragilis and Clostridium perfringens) because the transport process is active and oxygen-dependent. Facultative anaerobes (eg, enterobacteria and Staphylococcus aureus) are more resistant to the aminoglycosides when in an anaerobic environment. Impaired transport can be induced by exposure to sublethal concentrations of these antibiotics. Examples include streptomycin resistance among strains of Pseudomonas aeruginosa, low-level aminoglycoside resistance among enterococci, and gentamicin resistance in Streptococcus faecalis.

•         Impaired ribosomal binding may not be a clinically important form of resistance. Examples include Escherichia coli strains in which a single-step mutation prevents the binding of streptomycin to the ribosome. The same mechanism has been described in P aeruginosa.

•         Enzymatic modification of aminoglycosides may be either plasmid-encoded or chromosomally mediated. Enzymes occur in both gram-negative and gram-positive bacteria. There are 3 major types of enzymes involved, each including several subclasses: acetylating enzymes (acetyltransferases), adenylating enzymes (nucleotidyltransferases), and phosphorylating enzymes (phosphotransferases). The susceptibility of each aminoglycoside to specific enzymatic attack varies among each subclass. Although cross-resistance is common, there are differences in susceptibility patterns. Chemical modification stabilizes the drug, which decreases susceptibility to enzymatic destruction. For example, chemically modified kanamycin yields amikacin, which is more resistant to enzymatic hydrolysis.

•         Other mechanisms of resistance include: 1) increased concentration of divalent cations (especially Ca²⁺ and Mg²⁺), 2) increased production by P aeruginosa mutants of the outer cell membrane protein, H1, resulting in resistance to gentamicin, and 3) decreased pH, (eg, acidic urine or abscesses), which increases resistance to relatively high concentrations of aminoglycosides.

Antibacterial Spectra

•         Streptomycin and dihydrostreptomycin (no longer available in the USA) are characterized by narrow spectra, and efficacy is limited by bacterial resistance. Selected staphylococci and a number of gram-negative bacilli are still susceptible, including strains of Actinomyces bovis, Pasteurella spp, E coli, Salmonella spp, Campylobacter fetus, Leptospira spp, and Brucella spp. Mycobacterium tuberculosis is also sensitive to streptomycin.

•         The spectra of neomycin, framycetin, and kanamycin are broader, with clinical use targeting gram-negative organisms including E coli and Salmonella, Klebsiella, Enterobacter, Proteus, and Acinetobacter spp. Aminoglycosides whose spectra include P aeruginosa (gentamicin, tobramycin, amikacin, sisomicin, and netilmicin) are also often highly effective against a wide variety of aerobic bacteria. Anaerobic bacteria and fungi are not appreciably affected; streptococci are usually only moderately sensitive or quite resistant.

Pharmacokinetic Features

The pharmacokinetic features of the aminoglycosides are similar in most species.

Absorption

•         Aminoglycosides are poorly absorbed (usually <10%) from the healthy GI tract. However, permeability may be increased in the neonate and in the presence of enteritis and other pathologic changes, allowing absorption to be significantly greater. In the presence of renal failure, toxic concentrations may accumulate. Aminoglycosides can be administered slowly by bolus IV injection or SC or IM routes. Absorption from IM injection sites is rapid and nearly complete (>90% availability), except in severely hypotensive animals. Blood concentrations usually peak within 30–90 min after IM administration. Absorption after SC injection may be protracted. Absorption after IP administration can be rapid and substantial and has the potential to result in serious side effects. Short dosing intervals, including continuous infusions, are contraindicated. Once-daily therapy is indicated for safety considerations. Serum concentrations of aminoglycosides may reach bactericidal levels after repeated intrauterine infusion, particularly in endometritis.

Distribution

•         Aminoglycosides are polar at physiologic pH, limiting distribution to extracellular fluids with minimal penetration into most tissues. Exceptions include the renal cortex of the kidneys and the endolymph of the inner ear, sites at which aminoglycosides accumulate. The extracellular fluid compartment normally approximates 25% of body weight, but this volume can change substantially, which leads to indirectly proportional changes in the concentration of an aminoglycoside. For example, extracellular fluid space contracts with dehydration and during gram-negative sepsis, causing concentrations to increase; whereas the distribution volume of aminoglycosides increases with congestive heart failure or ascites, causing concentrations to decrease. Concentrations tend to be lower in neonates, which have a large extracellular fluid compartment relative to body weight. Aminoglycosides are not appreciably bound to plasma proteins (usually <20%). Therapeutic concentrations can be achieved in the synovial, pleural, and even peritoneal fluids, especially if inflammation is present. However, effective concentrations are not reached in CSF, ocular fluids, milk, intestinal fluids, or prostatic secretions. Fetal tissue and amniotic fluid concentrations are very low in most species.

•         Biotransformation, Excretion, and Pharmacokinetic Values

•         The aminoglycosides are excreted unchanged in the urine by glomerular filtration, with 80–90% of administered drug recoverable from the urine within 24 hr of IM administration. A variable fraction of filtered aminoglycoside is absorbed onto the brush border of the proximal tubule and loop of Henle cells. After binding, they are transported into the cell and sequestered in lysosomes and subsequently redistributed into the cytosol. Excessive accumulation (mainly in the renal cortex) leads to a characteristic tubular cell necrosis. Glomerular filtration rates differ between species and are often less in neonates, which may explain the greater sensitivity to aminoglycosides in newborn foals and puppies.

•         Elimination varies with glomerular filtration changes associated with cardiovascular and renal function, age, volume of distribution, fever, and several other factors. Half-life also will vary directly and proportionately with the volume of the extracellular fluid compartment. The aminoglycosides have relatively short plasma half-lives (∼1 hr in carnivores and 2–3 hr in herbivores). The elimination kinetics often follow a 3-compartment model, indicating a “deep” compartment. About 90% of the injected drug, including that within therapeutic concentrations, is excreted unchanged through the kidneys during the β phase of elimination. The remaining deep or γ phase is excreted over a protracted period, probably due to the gradual release of the antibiotic from renal intracellular binding sites (terminal elimination half-life often 20–200 hr). The limited selection of pharmacokinetic values for 2 typical aminoglycosides serves as a basis for any required dosage modifications that may be necessary due to age or renal insufficiency. The best way to alter a dosage regimen of aminoglycosides is to monitor plasma concentrations.

Elimination, Distribution, and Clearance of Aminoglycosides

Aminoglycoside	Species	Elimination Half-life (min)	Volume of Distribution (mL/kg)	Clearance (mL/kg/min)
Gentamicin	Dogs	75	335	3.10
	Horses	110	190	1.23
	Foals	200	300	1.04
Amikacin	Dogs	60	300	3.50
	Horses	45	207	0.75
	Sheep	115	200	0.70

Therapeutic Indications and Dose Rates

Despite their potential to cause nephrotoxicity, the aminoglycosides are commonly used to control local and systemic infections caused by susceptible aerobic bacteria (generally gram-negative). Several aminoglycosides are used topically in the ears and eyes, and via intrauterine infusion to treat endometritis.

Aminoglycosides occasionally may be infused into the udder to treat mastitis.

Clinical uses:

Streptomycin is widely used for the Rx of bovine streptococcal and staphylococcal mastitis (Streptopenicillin as oilt intramammary infusion), pasteurellosis and E. Coli infection (causing mastitis, metritis, enteritis and septicaemia in all species), leptospirosis (for clearance of organism from urine), tuberculosis and vibriosis.

Gentamicin is parenterally used in the Rx of G –ve septicaemia (drug of choice), urinary tract, GI tract, respiratory tract and topically in eye/ear infections.

Framycetin rarely used systemically because of ototoxicity and nephrotoxicity but used for the Rx of enteritis and topically for otitis externa in dogs.

Netilmicin is resistant to bacterial aminoglycoside inactivating enzymes and thus effective against gentamicin resistant strains.

Dosages of Aminoglycosides

Aminoglycoside                                             Dosage, Route, and Frequency

•         Gentamicin                                          6–12 mg/kg, IM or SC, sid

•         Kanamycin                                          25–30 mg/kg, IM or SC, sid

•         Streptomycin/dihydrostreptomycin    15–25 mg/kg, IM or SC, sid

•         Amikacin                                             15–22 mg/kg, IM or SC, sid

•         Netilmicin                                           6–12 mg/kg, IM or SC, sid

•         Neomycin                                            15 mg/kg, PO, sid-bid

                                                                        0.5–1 g/quarter, intramammary, sid

Dosage Modifications of Aminoglycosides in Renal Failure

Plasma creatinine (mg/dL)   Dose and Dosage Interval

•         <1                                            Full dose at usual dosage interval

•         2                                              Full dose doubling the usual dosage interval

•         3                                              Full dose tripling the usual dosage interval

•         4                                              Half dose doubling the usual dosage interval, or full

dose quadrupling the usual dosage interval

•         >5                                            Aminoglycosides contraindicated

The treatment interval should be increased in neonates (especially puppies and foals), in renal failure, and in obese animals. Doses may be increased in neonates or pediatric animals whose volume of distribution is greater than adults, and in animals with edema, hydrothorax, or ascites, provided their renal function is unimpaired.

Special Clinical Concerns

Adverse Effects and Toxicity

Ototoxicity, neuromuscular blockade, and nephrotoxicity are reported most frequently; these effects may vary with the aminoglycoside and dose or interval used, but all members of the group are potentially toxic.

Nephrotoxicity is of major concern and may result in renal failure due to acute tubular necrosis with secondary interstitial damage. Aminoglycosides accumulate in proximal tubular epithelial cells, where they are sequestered in lysosomes and interact with ribosomes, mitochondria, and other intracellular constituents to cause cell injury. The greater the ionization (eg, the more the amine groups and the lower the pH), the greater the active uptake. Persistence of aminoglycosides in plasma and thus urine is likely to predispose the tubular cells to toxicity, and the risk may by reduced by allowing plasma drug concentrations to drop below recommended concentrations (generally 1–2 μg/mL) before the next dose. Non-oliguric renal failure is the usual observation; it is generally reversible if damage is not sufficiently extensive to harm the basement membrane, although recovery may be prolonged.

Renal function should be monitored during therapy; however, no indicator of renal disease is sufficiently sensitive to prevent continued damage once nephrotoxicity is detected.

Polyuria, decreased urine osmolality, enzymuria, proteinuria, cylindruria, and increased fractional sodium excretion are indicative of aminoglycoside nephrotoxicity.

Later, BUN and creatinine concentrations may be increased. Early changes or evidence of nephrotoxicity can be detected in 3–5 days, with more overt signs in 7–10 days.

Several factors predispose to aminoglycoside nephrotoxicosis, including age (with young [especially the newborn foal] and old animals being sensitive), compromised renal function, total dose, duration of treatment, dehydration and hypovolemia, aciduria, acidosis, hypomagnesia, severe sepsis or endotoxemia, concurrent administration of furosemide, and exposure to other potential nephrotoxins (eg, methoxyflurane, amphotericin B, cisplatinum, and perhaps some cephalosporins).

In renal insufficiency, generally the interval between doses is prolonged (rather than reducing the dose) to minimize toxicity. Dosing in the morning may decrease toxicity in diurnal animals.

The risk of aminoglycoside-induced nephrotoxicity can be reduced by maintaining patient hydration and an alkaline urine pH, dosing once daily, dosing in the morning, and avoiding nephroactive drugs (eg, NSAID, diuretics).

Aminoglycosides can cause ototoxicity, which may manifest as either auditory or vestibular dysfunction.

Vestibular injury leads to nystagmus, incoordination, and loss of the righting reflex.

The lesion is often irreversible, although physiologic adaptation can occur.

Cats are particularly sensitive to the toxic vestibular effects, although occurrence at therapeutic concentrations following systemic administration is unlikely. However, aminoglycosides should not be administered topically into the ear unless the tympanic membrane is intact.

Hearing impairment reflects permanent damage and loss of the hair cells in the organ of Corti. Loss of high-frequency hearing is followed by deafness, which may not be complete if sufficiently low doses or durations were used. Aminoglycosides should be avoided in working dogs that depend on hearing (eg, guide dogs).

Factors increasing the risk of vestibular and cochlear damage are the same as for nephrotoxicity, but also include pre-existing acoustical or vestibular impairment and concurrent treatment with potentially ototoxic drugs.

The ototoxic potential is greatest for gentamicin, sisomicin, and neomycin, and least for netilmicin.

All aminoglycosides, when administered in doses that result in high plasma concentrations, have been associated with muscle weakness and respiratory arrest attributable to neuromuscular blockade.

The effect is more pronounced when aminoglycosides are used with other drugs that cause neuromuscular blockade and with gas anesthetics.

Neomycin, kanamycin, amikacin, gentamicin, and tobramycin are listed in order of most to least potent for these neuromuscular effects.

The effect is due to the chelation of calcium and competitive inhibition of the prejunctional release of acetylcholine in most instances (there are some differences among aminoglycosides). The blockade is antagonized by calcium gluconate and somewhat less consistently by neostigmine.

CNS disturbances rarely include convulsions or collapse after rapid IV administration.

Other side effects include superinfection when used topically or PO, a malabsorption syndrome due to attenuation of intestinal villous function when used PO in neonates, occasional hypersensitivity reactions, contact dermatitis, cardiovascular depression, and inhibition of some WBC functions (eg, neutrophil migration and chemotaxis and even bactericidal activity at high concentrations).

Contraindications and precautions

To be avoided in pregnancy (fetal toxicity), along with other ototoxic drugs (high ceiling diuretics, minocycline, etc) and with other nephrotoxic drugs (amphotericin B, cephaloridine, etc.).

Neomycin is contraindicated in animals prone to post parturient hypocalcemia.

Interactions

Enhanced nephrotoxicity may become evident with concurrent administration of aminoglycosides and other potentially nephrotoxic agents.

Neuromuscular blockade is more likely when aminoglycosides are administered at the same time as skeletal muscle relaxants and gas anesthetics. Aminoglycoside ototoxicity is enhanced by the loop-acting diuretics, especially furosemide. Cardiovascular depression may be aggravated by aminoglycosides when administered to animals under halothane anesthesia. High concentrations of carbenicillin, ticarcillin, and piperacillin inactivate aminoglycosides both in vitro and in vivo in the presence of renal failure.

Effects on Laboratory Tests

•         BUN, serum creatinine, serum transaminases, and alkaline phosphatase values may be increased. Proteinuria is a significant laboratory finding.

Drug Withdrawal and Milk Discard Times of Aminoglycosides

Route              Approximate Withdrawal Time (days)

Oral                 20–30 (3 for neonatal pigs)

Parenteral        100–200 (40 for neonatal pigs [often not approved for food             animals])

Udder infusion            2–3^a (often not approved for food animals)

                                                ^a Milk discard time

Miscellaneous Aminocyclitol Antibiotics

Apramycin is used to control gram-negative infections, particularly Escherichia coli and salmonellae in calves and piglets. It also is active against Proteus, Klebsiella, Brachy-spira, and Mycoplasma spp.

There is little cross-resistance within the aminoglycosides, and plasmid-mediated resistance is yet to be confirmed.

Apramycin is poorly absorbed after administration PO (<10%). It is rapidly absorbed from parenteral injection sites. Plasma concentrations peak within 1–2 hr of IM administration. Apramycin distributes only into the extracellular fluid and is excreted unchanged in the urine (95% within 4 days). The elimination half-life in calves is ∼4–5 hr.

Apramycin is toxic in cats but is considered safe in most other species (3–6 times the recommended oral dose rarely produces toxicity).

The oral dose rate is 20–40 mg/kg, sid for 5 days. The parenteral dose rate is 20 mg/kg, bid.

The withdrawal time in pigs and calves (in Europe) is 28 days after oral use.

The structure of spectinomycin differs from that of the aminoglycosides, but it also binds to bacterial ribosomes and interferes with protein synthesis. However, the effect is bacteriostatic rather than bactericidal.

Spectinomycin can be inactivated by an enzyme coded for by an R factor, but mutant resistance due to diminished ribosomal binding is perhaps more common.

It is active against several strains of streptococci, a wide range of gram-negative bacteria, and Mycoplasma spp; most Chlamydia spp are resistant.

It is poorly absorbed from the GI tract but is rapidly absorbed after IM administration, with blood concentrations peaking within 1 hr. Like aminoglycosides, spectinomycin penetrates tissues rather poorly and distributes principally into extracellular fluid. Metabolic transformation of spectinomycin is limited, and 80% can be recovered unchanged in the urine over 24–48 hr. About 75% is eliminated by glomerular filtration in ∼4 hr.

At usual doses, no major toxic reactions have been reported.

It is administered both PO at 20 mg/kg, bid, and IM at 5–10 mg/kg, bid. Withdrawal time for pigs is usually ∼3 wk.