Tetracyclines are used to treat many gram-positive and gram-negative bacteria. They are also effective on some protozoa. In other words they are used against a large variety of infections. (Todar K.T 2009). However due to the issue of bacterial resistance, these antibiotics have significantly decreased in value. (Speer et al.1992).
Tetracyclines are mainly used as a treatment for acne, eye infections, pneumonia, gonorrhea, Rocky Mountain spotted fever, urinary tract infections and Lyme disease. (Ogbru and Marks 2008). Other bacterial infections which usually result in the prescription of tetracyclines include Chlamydia, rickettsia, brucella and the spirochaeta. As well as the previously mentioned, there are many other infections in which tetracyclines are administered since it is such a broad spectrum antibiotic.
Tetracyclines, for example Tetracycline hydrochloride, Demeclocycline hydrochloride, Doxycycline, Lymecycline, Oxytetracycline, Tigecycline are essentially able to treat the same infections. Minocycline, another member of the tetracycline family, has a broader spectrum; it is active against Neisseria Meningitidis as well as the infections treated by the other tetracyclines.
Tetracyclines have similar side effects but each individual drug does come with some added ones. These include nausea, vomiting, diarrhoea, dysphagia (difficulty in swallowing), and oesophageal irritation. Other rare side effects have been noted such as acute renal failure and skin discolouration. (Joint Formulary Committee 2007, British Medical Association and Royal Pharmaceutical Society of Great Britain2008).
The dosages of tetracyclines i.e. when taken orally are usually 250mg, every 6 hours. This should be increased in severe infections to 500mg every 6-8hours. However this dosage does not apply to the different types of tetracyclines; each specific tetracycline has a specific dosage according to its strength. (Joint Formulary Committee 2007, British Medical Association and Royal Pharmaceutical Society of Great Britain 2008).
四环素类药物是用于治疗革兰氏阳性菌和革兰氏阴性菌。他们也有一些原生动物。换句话说，它们是用来对付各种各样的感染的。（Todar K. 2009）。然而，由于细菌耐药性的问题，这些抗生素有显着下降的价值。（Speer等人，1992）。
四环素类药物主要用于治疗痤疮、眼部感染、肺炎、淋病、落基山斑疹热，尿路感染莱姆病。（Ogbru和标志2008）。在对四环素类抗生素的处方，通常会导致其他细菌感染包括衣原体、立克次体、螺旋体、布鲁氏菌。如前面所提到的，还有很多其他的感染，四环素类药因为它是这样一种广谱抗生素。
四环素类药物，例如盐酸四环素、盐酸去甲金霉素，强力霉素，赖甲四环素，土霉素，替加环素是能够把同样的感染。米诺环素，四环素家族的另一成员，有一个广泛的；它是积极反对Neisseria Meningitidis以及其他四环素类抗生素治疗感染。
四环素类药物有相似的副作用，但个别药物也会有加的。这些包括恶心，呕吐，腹泻，吞咽困难（吞咽困难），和食管的刺激。其他罕见的副作用已经指出如急性肾功能衰竭和皮肤变色。（联合药典委员会2007个，英国医学协会和大britain2008皇家医药学会）。
的剂量口服四环素即通常250mg，每6小时一次。这应该是在严重感染增加500mg每6-8小时。然而这种剂量不适用于四环素类药物的不同类型；根据其强度每一个具体的四环素具有特定的剂量。（联合药典委员会2007个，英国医学协会和英国皇家药学会2008）。
Mechanism of Action of tetracyclines
In order to understand the mechanism of action of tetracyclines, and therefore their role as antibiotics, it is important to have a basic understanding of bacterial protein synthesis in bacteria. An outline of this process at the ribosomal level is given in the diagrams below:
Figure 1: Taken from Simmer (2003)
Figure 1 shows the importance of the binding of aminoacyl-tRNA at the A site to allow successful elongation of the peptide chain (shown in the first step of elongation in Figure 1). In bacteria, the tetracyclines inhibit protein synthesis at the level of the ribosome through a process of disruption of codon-anticodon interactions between tRNA and mRNA. As a result of this the binding of aminoacyl-tRNA to the ribosomal acceptor (A) site is prevented and bacterial growth is inhibited (Gale et al., 1981; Chopra, 1985). The precise mechanism by which the aminoacyl-tRNA is prevented from attaching to the A site by the tetracyclines is not understood. It has been suggested that inhibition is likely to result from interaction of these antibiotics with the 30S ribosomal subunit since many of the tetracyclines are known to bind strongly to a single site on the 30S subunit (Chopra 1985 cited Chopra et al., 1992)
Tetracyclines also bind to DNA, proteins and synthetic polynucleotides but it is only the binding to ribosomes that is inhibitory and, therefore, has a therapeutic effect (Gale et al., 1981).
The structure of the tetracycline drug molecules can affect their antibacterial activity. "Features important for antibacterial activity among the tetracyclines are maintenance of the linear fused tetracycle, naturally occurring (a) stereochemical configurations at the 4a, 12a (A-B ring junction), and 4 (dimethylamino group) positions, and conservation of the keto-enol system (positions 11, 12, and 12a) in proximity to the phenolic D ring" (Chopra and Roberts, 2001). Research carried out by McCormick et al. (1957 cited Gale et al., 1981) also draws attention to the fact that the configuration of the 4-dimethylamino group must not be reversed (which would give 4-epitetracycline) as this would cause antibacterial activity to be lost.
However, since the precise mechanism by which tetracylines work is not fully understood, further knowledge of how the structure of the drug molecules affects their function as antibiotics is not known.
Social impact of tetracyclines
The basic health of a population is essential for society. The US Food and Drug Administration, as well as the British National Formulary list a range of indications for administering tetracyclines. A target area concerning the use of tetracyclines is the current epidemic of sexually transmitted infections (STIs). One bacterium susceptible to tetracyclines includes Chlamydia trachomatis which is responsible for Chlamydia. If untreated, Chlamydia can lead to serious health complications including infertility and as the condition exhibits asymptomatic effects, rapid intervention is necessary.
National statistics state that Chlamydia is the most common STI in the UK and has been on the rise since the early 1990's. Chlamydia can potentially affect any sexually active individual; however figures dictate that 15 to 24 year olds are at higher risk and the majority of cases are found in women. Chlamydia infections can possibly spread in pregnant women, passing the disease onto their children who may be born premature and with serious conditions such as blindness and pneumonia. The issue for society arises as tetracyclines, normally the primary choice for Chlamydia patients, have been shown to possess toxic effects on bones and therefore must not be distributed to children under the age of eight and pregnant women if impaired development of the foetus's bone structure is possible.
An additional common use for tetracycline is in patients with acne. Tetracycline is often prescribed for patients with moderate to severe acne. The drug targets inflammatory lesions caused by Propionbacterium acnes affecting the pilosebaceous unit of the skin. The University of Newcastle-Upon-Tyne reported in the 'Journal of Dermatological Treatment' that there was a shift in the peak age incidence of acne between 14-26 year olds. Therefore acne is making an impact on the working population.
Although tetracyclines target bacterial diseases, a preventative approach to control the spread of disease would be ideal. However demographic changes, including a steep increase in populations and consequently urbanisation leads to overcrowding. The resulting situation can potentially lead to poor sanitisation and the spread of diseases including respiratory infections. In more economically developed countries this issue can be tackled as tetracyclines are dispensed for diseases including respiratory mycoplasma infections and exacerbations of chronic bronchitis caused by Hemophilus influenza. However on a global scale, lesser economically developed countries without funding or national health services, as in the UK, see an increased level of occurrence of diseases in lower and middle social classes.
Our final point concentrates on one of the drawbacks of tetracyclines. As tetracyclines are common broad spectrum antibiotics, their use has encouraged evolutionary transformation and subsequently the prevalence of bacterial resistant strains. Resistance of tetracyclines has been identified and so to a certain degree, limits their use. Future implications include the degree of effectiveness they directly impose on infections. There are many relative contributors when discussing the cause of resistance strains. For example many doctors have been criticised for prescribing antibiotics too freely to the extent that the European centre of Disease Prevention and Control sent out letters to every general practioner to reiterate to them the complications of routinely prescribing these drugs.
Many civic groups have been created to increase public awareness of the dangers of resistance strains of antibiotics including tetracyclines. The underlying fear is that antibiotics will eventually cease to be the effective tool in fighting infections, limiting choices for both physicians and patients. In November 2008, 27 European member nations celebrated 'Antibiotic Awareness Day'. Their objectives included raising awareness on how to use antibiotics in a responsible way, hoping for them to remain effective for the future.
Economic impact of tetracyclines
Tetracyclines are antibiotics which are produced by the pharmaceutical industry. Ultimately, any profit made by the industry results in indirect revenue for the country. So it follows that the greater the sale, the greater the tax revenue. Furthermore, in producing drugs that would keep a population healthy, the number of man hours lost to illness is reduced. In producing new and established drugs, the pharmaceutical industry creates opportunities for a great number of highly skilled workers. In the process of producing these drugs, the pharmaceutical industry must consider the most cost efficient means available.
There are many economic factors that pharmaceutical industries must address when formulating a new drug. Antibiotics such as tetracyclines can be used to treat a wide range of infections, meaning there is high demand for them and a lot money invested in their development and production. The production of antibiotics is worth millions of pounds and continues to expand each year. Over 10,000 antibiotic substances have been discovered and this number is increasing as new antibiotics are being created and developed synthetically.
The discovery of new antibiotics is a very complex process which takes years and furthermore is very costly. Microorganisms are cultured and then tested for their therapeutic index by allowing them to diffuse onto a range of different products such as bacterial cultures. This is to observe the effectiveness of their antibacterial properties. However, most of these antibiotics produced in this way have already been discovered. Therefore these new compounds may be modified to fulfil different roles and target different bacteria. Pfizer were the original producers of the first tetracyclines and are the main choice when the proprietary band is prescribed. However, the non-proprietary is most commonly prescribed - most likely due to cost for the NHS.
The production of antibiotics is said to be a batch process, as contamination would be more likely within a continuous process. Although a continuous process is quicker, the wastage caused by contamination means it isn't a cost effective process. Fermentation is used to allow the selected microorganisms to multiply and produce the antibiotic on a large scale. The selected organism which produces the antibiotic is isolated and a starter culture is made to increase the numbers of available organisms. Next, the medium is transferred to fermentation tanks where the microorganisms are able to grow and multiply, so large amounts of the antibiotic are produced. After a number of days a maximum level of antibiotic will have been produced by the microorganisms and separation of the products can begin. Various different purification methods can be used e.g. organic chemicals, leaving a purified powder. This whole process takes a few days meaning huge quantities can be manufactured each year worth millions of pounds to the producers.
Different formulations are then produced such as tables, capsules, intravenous drips. The type of formulation will affect how much the drug will cost the customer. For example tablets are the cheapest as they are the easiest to produce and they are combined with cheap materials/ chemicals in formulation. Conversely, an intravenous preparation will be more expensive as a solvent is used to dissolve the drug. Packaging and transport costs also affect the economic factors related to the drug. Tablet formulations are cheap as they are packed tightly in boxes and are not easily damaged. This contrasts to the high cost required to transport other formulations in suitable conditions. Environmental factors can affect the drug such as temperature and suitable transportation methods are needed to deliver the product safely without damage.
It is important to consider Quality Assurance throughout the production process. As mentioned earlier it is very easy for contamination to occur during the manufacture. So Quality Assurance is completed by checking the product on a regular basis. This is very time consuming and requires staff, however, if contamination were to occur there would be a greater loss of money through wastage and time. It is also very important to ensure the highest quality of product is produced as patients' health is dependent on the drug and if errors were to occur, the company in fault could be fined and acquire a bad reputation.
In the manufacture process the major costs of the materials is in the production of the fermentation culture. It contains essential ingredients that the microorganisms need for growth and reproduction. Most importantly there will be a carbon source (molasses/ sugars). Nitrogen is also essential mostly in metabolic pathways which take place in the organism. Other elements are also necessary: phosphorus, iron, and copper. These are added as salts. Also, foaming is prevented during the fermentation process by adding anti-foaming agents such as octadecanol.
The majority of the materials used in production would be sourced locally however more specific materials may need to be imported from other countries. Importing the materials will introduce greater costs in the production due to transportation and workers' wages. However, it would benefit the overall economy as more jobs would be produced in the country of origin and the money would ultimately be returned, with a profit to the producers, through the sale of the product.
Another area that requires a certain amount of economic consideration is the energy requirements in the production and distribution stages. Certain temperatures need to be produced to enable the fastest rate of reaction, and many pieces of equipment will be used which require electricity to power them. A lot of energy will also be required for transportation like petrol for lorries.
When a customer is prescribed tetracyclines, they are required to pay the standard NHS prescription cost of 7.20 pounds due to it being a Prescription only medicine. However the tablets themselves are relatively cheap; according to the BNF 1 tablet costs approx 20p therefore the real cost of a pack for a complete course may be cheaper than the standard NHS charge. But the fact that the cost is relatively high may prevent overuse/misuse. Another problem the NHS may consider is whether its use outweighs its higher cost of production/purchase. However, since tetracyclines are so cheap to manufacture, there is no issue with distributing this drug on the NHS with the usual levy charge.
The maximum shelf life for tetracyclines is 1 year after which it can deteriorate into a toxic compound. This time is relatively long and so is an advantage to the manufacturer. To save further costs it may be kept in a powder form to prevent hydrolysis in solution, which could decrease the shelf life further still. Once taken, their half life is 6-11 hours (Paracetamol 1-4 hrs) meaning they will be fully functional for a long time. Therefore a lower dosage is required hence lowering the cost of production even further. The type of formulation will also affect the antibiotic's strength/effectiveness; if they are injected they will be even more effective as they will reach the target area more quickly, through the blood stream. However the cost of production would be much higher and therefore this formulation may only be chosen in preference of the cheaper tablets in certain circumstances.
There are other similar competitive drugs on the market for example penicillins. However tetracyclines are normally chosen by preference. This may be due to the fact that fewer people are allergic to them, they have fewer side effects or because they are very broad spectrum antibiotics. Other pharmaceutical companies create competition for each other as they may produce the same drugs as each other or may produce cheaper alternatives that are just as effective. This creates lowering prices and can affect the economy of the companies. This can be prevented by patenting laws. When new drugs are discovered the pharmaceutical company will obtain a patent for this drug allowing them sole production rights. However, after a certain length of time these run out.
Development of new drugs is a very costly process but due to bacterial resistance, new antibiotics are always required. This may mean discovering new antibiotics or modifying existing ones to allow them to remain in use for longer. Antibiotics are an essential part of medicine and therefore play a major part in the economy.
有其他类似的竞争药物如青霉素类市场。然而，四环素类抗生素通常选择偏好。这可能是由于这样的事实，更少的人对他们过敏，他们有较少的副作用，或因为他们是非常广谱抗生素。其他制药公司为彼此创造竞争，因为他们可能会产生相同的药物，或可能会产生更便宜的替代品，是有效的。这造成了降低价格，并会影响公司的经济。这可以通过专利的法律阻止了。当新药被发现时，制药公司将获得这种药物的专利权，允许他们单独生产权利。然而，在一定的时间长度后，这些耗尽。
开发新的药物是一个非常昂贵的过程，但由于细菌耐药性，新的抗生素是必需的。这可能意味着发现新的抗生素或修改现有的，让他们保持在使用更长的时间。抗生素是医学的重要组成部分，因此在经济中起着重要的作用。