Possible new ways for the development of novel classes of antibiotics are discussed here, for which there is no pre-existing resistance in human bacterial pathogens. By utilizing research and technology such as nanotechnology and computational methods (such as in silico and Fragment-based drug design (FBDD)), there has been an improvement in antimicrobial actions and selectivity with target sites. Moreover, there are antibiotic alternatives, such as antimicrobial peptides, essential oils, anti-Quorum sensing agents, darobactins, vitamin B6, bacteriophages, odilorhabdins, 18β-glycyrrhetinic acid, and cannabinoids. Additionally, drug repurposing (such as with ticagrelor, mitomycin C, auranofin, pentamidine, and zidovudine) and synthesis of novel antibacterial agents (including lactones, piperidinol, sugar-based bactericides, isoxazole, carbazole, pyrimidine, and pyrazole derivatives) represent novel approaches to treating infectious diseases. Nonetheless, prodrugs (e.g., siderophores) have shown to be an excellent platform to design a new generation of antimicrobial agents with better efficacy against multidrug-resistant bacteria.
1. Introduction
Prior to the turn of the 20th century, infectious diseases were the main contributor to high morbidity and mortality rates around the world
[1]. The period of antibiotics, which saw the discovery and development of numerous antibacterial drugs, began with Fleming’s discovery of penicillin in 1929. Regrettably, the emergence of resistant strains was brought on by the overuse and careless use of antibiotics
[2][3][2,3]. According to 2019 systemic analytic research, there were 4.95 million fatalities attributable to antimicrobial resistance (AMR). With 27.3 deaths per 100,000 people, western sub-Saharan Africa has the highest mortality rate, whereas Australasia has the lowest mortality rate with 6.5 deaths per 100,000 people
[4]. Twelve families of bacteria have been identified by the World Health Organization (WHO) as the most dangerous to human health and have been divided into three priority groups: critical pathogens (
Acinetobacter,
Pseudomonas,
and Enterobacteriaceae), high priority pathogens (
Enterococcus faecium,
Staphylococcus aureus,
Helicobacter pylori,
Campylobacter,
Salmonella spp.,
Nisseria gonorrhoeae), and medium priority pathogens (
Streptococcus pneumoniae,
Shigella spp.)
[5][6][7][8][5,6,7,8]. The presence of multidrug-resistant (MDR) ESKAPE pathogens (including
Enterococcus faecium,
Staphylococcus aureus,
Klebsiella pneumoniae,
Acinetobacter baumannii,
Pseudomonas aeruginosa, and
Enterobacter species) and extensively drug-resistant (XDR) bacteria has rendered even the most effective drugs ineffective. Therefore, its necessary to develop novel strategies and approaches to overcome the problem of increasing AMR
[9][10][11][9,10,11].
2. Antibiotic Classification
New antibiotic use methods should be implemented on a local and global level to combat resistance, and the development of novel treatments requires a thorough understanding of how antibiotics function.
Table 1 summarizes how antibiotics produce their effects through a variety of mechanism of action. Antibiotic-mediated cell death is a complicated process that begins with a physical interaction between the medication and its particular target in bacteria, altering the bacterium’s biochemical, molecular, or ultrastructural levels. The development of DNA double-stranded DNA breaks, the halting of DNA-dependent RNA synthesis, cell envelop damage, protein mistranslation, and stress induction are only a few of the methods through which antibiotics can cause cell death
[12]. Antimicrobial agents are divided into two categories on the basis of how they affect bacteria in a test tube: (1) bactericidal (kill bacteria) antibiotics such as β-lactams, glycopeptides, lipopeptides, rifamycins, aminoglycosides, and fluoroquinolones, and (2) bacteriostatic (prevent bacterial growth) antibiotics such as sulfonamides–trimethoprim and macrolides. Bacteriostatic substances can also be described as having a minimum bactericidal concentration (MBC) to minimum inhibitory concentration (MIC) ratio higher than four, and bactericidal substances when the MBC to MIC ratio is lower than or equal to four
[13].
Table 1.
List of antimicrobial agent and their mechanism of action.
Figure 1. Chemical structure of penicillins, cephalosporins, carbapenems, monocyclic β-lactams, clavulanic acid (β-lactamase inhibitors), vancomycin, teicoplanin, telavancin, dalbavancin, and oritavancin.
Figure 2.
Chemical structure of polymyxins, daptomycin, amphomycin, friulimicin, ramoplanin, and empedopeptin.
Figure 3.
Chemical structure of rifampin, rifabutin, rifapentine, streptomycin, apramycin, tobramycin, gentamycin, amikacin, neomycin, arbekacin, and plazomicin.
Figure 4. Chemical structure of nalidixic acid, enoxacin, norfloxacin, ciprofloxacin, ofloxacin, lomefloxacin, sparfloxacin, grepafloxacin, clinafloxacin, gatifloxacin, moxifloxacin, gemifloxacin, trovafloxacin, arenoxacin, sulfamethoxazole, trimethoprim, erythromycin, clarithromycin, azithromycin, fidaxomicin, and telithromycin.
Figure 5. Chemical structure of chlortetracycline, oxytetracycline, tetracycline, demeclocycline, doxycycline, minocycline, lymecycline, meclocycline, methacycline, rolitetracycline, tigecycline, omadacycline, sarecycline, eravacycline, linezolid, sutezolid, eperezolid, delpazolid, tedizolid, tedizolid phosphate, radezolid, and TBI-223.
Figure 6.
Chemical structure of quinupristin, pristinamycin, virginiamycin, chloramphenicol, thiamphenicol, florfenicol, lincomycin, and clindamycin.
3. Antimicrobial Resistance
The World Health Organization (WHO) describes antimicrobial resistance as a natural phenomenon that happens when germs cease responding to antibiotics that they were previously susceptible to before. Resistance makes treating infections more difficult or impossible
[8][32][8,32]. In bacteria, there are two types of resistance: acquired and natural
[33]. Natural resistance can either be produced or intrinsic (expressed in a species without connection to horizontal gene transfer) (the natural bacterial genes are only expressed to resistance levels after exposure to an antibiotic). Contrarily, acquired resistance can develop after acquiring genetic material that already exhibits it through horizontal gene transfer (HGT) (transformation, transposition, and conjugation) or by causing a mutation in the cell’s DNA during replication
[8][33][34][8,33,34]. Antimicrobial resistance mechanisms include drug inactivation, decreased intracellular drug concentration, and altered drug targets (
Figure 7)
[35][36][35,36]. One of the most significant mechanisms of acquired resistance is the change or degradation of antibiotics. Bacterial enzymes have the ability to alter a number of antibiotics, including aminoglycoside, chloramphenicol, and β-lactam
[37][38][37,38]. By increasing efflux or decreasing influx, one can lower drug concentration
[39]. Bacteria can develop a high level of inherent resistance owing to this method. Porin mutations in resistant strains alter the permeability of bacterial membranes, which reduces medication uptake into the cell. For instance, OprD, a particular porin in strains of
P. aeruginosa, can result in a mutation for carbapenem resistance
[40]. The Proteobacterial Antimicrobial Compound Efflux (PACE) superfamily, the Resistance Nodulation Division (RND) family, the Small Multidrug Resistance (SMR) superfamily, the Multidrug and Toxic Compound Extrusion (MATE) superfamily, and the ATP (adenosine triphosphate)-Binding Cassette (ABC) superfamily are the six families that make up the transmembrane proteins that make up efflux pumps
[41][42][41,42]. The most prevalent efflux pumps in both Gram-positive and Gram-negative bacteria are MFS and RND pumps
[39]. The medication target changing is another method of resistance. Examples include the resistance to glycopeptide and polymyxin antibiotics caused by enzymes that chemically alter components of the cell membrane necessary for antibiotic binding. Methyltransferases are another example of target modifying enzymes since they change the rRNA elements on the ribosome and thus become resistant to antibiotics including aminoglycoside, lincosamide, macrolide, streptogramin, and oxazolidinone
[43]. Another phenomenon known as “target protection” occurs when an antibiotic target’s resistance protein protects it from antibiotic-induced inhibition (target protection protein). Tetracycline ribosomal protection proteins (TRPPs) are an illustration of this mechanism
[44].
Figure 7.
Mechanism of antimicrobial resistance which include reduce intracellular antibiotic concentration, antibiotic inactivation, and target site alteration.
4. Antibiotic Use and Resistance in Agriculture Sector
β-lactams, aminoglycosides, tetracyclines, macrolides, and other antibiotics with comparable modes of action to those used by humans are causing a lot of concern due to their possible side effects and risk management strategies
[45]. Because medicines are available over the counter, their overuse, abuse, and misuse are linked to antibiotic resistance
[46]. Antibiotic resistance is caused by the use of antibiotics in animals raised for food. Food safety and public health may suffer if antibiotic residues are found in products obtained from animals that are intended for human consumption
[47][48][49][47,48,49]. Use of unnecessary antibiotics in animals for the purpose of promoting development, as well as waste products from veterinary care and livestock farming, human waste streams, and soil fertilization, can result in the release of antibiotics pollution into the environment. As a result, it is possible to think of the environment as a reservoir for antibiotics and bacteria that are resistant to antibiotics, and their resistance genes
[45][50][51][52][45,50,51,52]. Reports that some bacterial infections in humans are brought on by animal pathogens (zoonotic pathogens) such as
Salmonella spp.,
Staphylococcus spp.,
Yersinia enterocolitica,
Enterococcus spp.,
Listeria monocytogenes,
Campylobacter jejuni and
Escherichia coli [53][54][55][53,54,55] have demonstrated that antibiotic resistance can be transmitted directly or indirectly from animal to human. To prevent antibiotic resistance and maintain the potency of the available antibiotics, a number of practices should be regulated for the prudent use of antibiotics in the clinical and agricultural sectors
[56][57][56,57]. The demand for antibiotics to cure illnesses can be decreased by improving animal feed, waste management, and animals’ natural immunity. Moreover, using antibiotic alternatives including prebiotics, probiotic vaccines, and bacteriophages can help reduce the need for antibiotics
[58][59][60][58,59,60].