Pharm 4 antibacterials
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How do we choose what drug to use for what microbe?
How do we choose which drug to use?
consider selective toxicity & classification of the drug
How is penicillin aqueous admin?
drugs kill microbe without harming host cells
3 ways antimicrobials are classified?
- 1. susceptible organism
- 2. mechanism of action
- 3. bactericidal or bacteriostatic
When will anaphylaxis usually occur?
w/in first 30 minutes of admin
Bactericidal or bacteriostatic?
bactericidal - kills microbe
- bacteriostatic - inhibit growth
- depends on body's defense mechanism more than bactericidal
6 factors to consider when choosing the correct drug?
- 1. pathogen causing infection
- 2. drug susceptibility
- 3. broad or narrow spectrum
- 4. time takes drug to fight pathogen
- 5. infection site
- 6. pt health/assessment
give broad spectrum ABX until C&S is done then give correct ABX
must draw culture sample before giving ABX or ABX will mess up the samples
Why is it important to choose a drug with the narrowest possible spectrum?
- 1. limits potential for AE like superinfection
- 2. more specific
What may be used instead of broad spectrum ABX that is more specific?
Why may a broad spectrum ABX cause a superinfection?
more likely to kill normal flora
superinfection- infection that occurs during Tx of primary infection
suprainfection- secondary infection usually caused by an oppurtunistic infection
2 things that may occur with ABX TX?
ABX can kill normal flora & may cause:
- 1. superinfection with secondary microbe
- 2. resistant microbe
2 lab test that help with drug selection?
What 2 things are determined with gram staining?
- 1. gram + or -
- 2. aerobic or anaerobic
What type of microbes does penicillin work best against?
What type of ABX is antibiotic resistance most likely to occur with?
broad spectrum ABX
4 reasons resistance may occur?
- 1. microbe produces drug inactivating enzymes
- 2. improper drug conc., dose strength, or length b/t doses
- 3. not taking all the drug
- 4. prophylactic use of ABX
What ABX is used a lot for procedures/
4 important ABX-resistant microbes?
- 1. MRSA - methicillin-resistant staphylococcus aureus
- 2. MDR - TB - multiple drug resistant mycobacterium tuberculosis
- 3. Penicillin-resistant streptococcus pneumoniae
- 4. VRE - vancomycin resistant enterococcus
If pt starts to feel bad after admin of ABX what should be done?
do assessment and be sure it is not allergic response
Where does VRE usually occur?
in the urine
Why does resistance often occur in mycobacterium tuberculosis?
Treated with multiple drugs & long-term
Teaching for missed ABX dose?
take ASAP but never double up
Pt teaching for ABX?
- 1. how long it takes ABX to work
- 2. keep away from CH
- 3. S/S of AE and allergic reaction
- 4. women of CH-bearing age need back-up BC b/c interferes with oral contraceptives
S/S of allergic/anaphylactic response?
- 1. throat discomfort of any kind
- 2. sunburn-like rash
- 3. itching
2 drugs that are highly likely to have cross allergy with each other?
penicillin and cephalosporins
Which ABX is the only drug in its class?
5 ABX that affect the bacterial cell wall?
They are all ______ & may have ______ ______.
- 1. penicillin
- 2. cephalosporins
- 3. monobactams
- 4. carbapenems
- 5. vancomycin
Which ABX that affects the cell wall is least like the other ABX in this family?
can be taken with penicillin allergy
What type of ABX are penicillins?
What is beta lactam?
special ring chemical structure of penicillins and their family that is essential for their ABX activity
4 different types of penicillin?
- 1. narrow-spectrum penicillinase sensitive
- 2. narrow spectrum penicillinase resistant
- 3. broad-spectrum
- 4. extended spectrum
Consideration for admin?
give on empty stomach
What type of penicillin may be used IV?
Most common AE of penicillin?
Most serious AE of penicillin?
Contraindications with with penicillin?
contraindicated with allergies to penicillin, cephalosporins, and imipenem
Assess pt carefully for ____ ______ especially with the ______ dose.
When should pt be monitored most closely for allergic reactions?
within the first 30 minutes of admin
What should be kept close when admin ABX?
EPI & resusitation equipment
2 things nurse should do prior to the admin of penicillins?
- 1. check for allergies to penicillin, any other "cillins", or cephalosporins
- 2. check C&S
3 nursing responsibilities after the admin of penicillins?
- 1. Evaluated effectiveness of drug/improvement
- 2. monitor for suprainfections: candida
- 3. monitor I&O & s/s of allergic response
Why monitor I&O with penicillins?
make sure kidneys not affected
drugs that may be given with penicillins or other beta-lactam drugs
binds to beta-lactamase produced by bacteria that stops the action of penicillin
allows penicillin to reach target site so it can act
Infections that may be Tx with penicillins?
pneumonia, pharyngitis, tonsillitis, endocarditis, scarlet fever, tetanus, anthrax, meningitis, syphilis, diptheria,
3 types of betalactam ABX besides penicillin?
- 1. monobactams
- 2. carbapenems
- 3. cephalosporins
What type of bacteria are monobactams best for?
They have no action with ____ or ______ microbes
gram negative aerobic bacteria
gram + or anaerobe
Diff b/t monobactams & other beta-lactams?
have very diff chem structure from others
Drug that is a monobactam?
Carbapenems end with ______.
Carbapenems are _____ spectrum
2 most commonly seen carbapenems?
- 1. ertapenem/Invanz
- 2. meropenem/Merrem
2 uses for carbapenems like ertapenem & meropenem?
- 1. abdominal infections like peritonitis
- 2. nosocomial infections
Ertapenem & meropenem require decreased dose with _____ ______.
What type of microbes do cephalosporins Tx?
gram positive & anaerobes
Use for cephalosporins?
GI or GU surgery
Why does cross sensitivity occur b/t cephalosporins an penicillins?
they are very similar in structure
Drug of choice for penicillin allergies?
Why are cephalosporins the most commonly prescribed ABX?
What problem does this cause?
they are effective and cheap
resistance is developing
How are the generations of cephalosporins different?
- 4 generations & with each generation:
- 1. increased activity against gram-neg bacteria
- 2. increased resistance to beta-lactamase
- 3. increased ability to reach CSF
Use for cefazolin/Ancef?
prophylaxis for surgery & artificial parts like pacemakers
Most common AE of cefazolin/Ancef?
NVD & decreased appetite
Most serious AE of cefazolin/Ancef?
Interactions with cefazolin/Ancef?
can have acute alcohol intolerance if used with alcohol
3 nursing actions to do before admin of cefazolin/Ancef?
- 1. check for allergy to cephalosporins/"ceph"/"kef" drugs
- 2. check for allergy to penicillin/"cillins"
- 3. check C&S
3 things to monitor with admin of cefazolin/Ancef?
- 1. effectiveness of med/improvement
- 2. monitor for suprainfections
- 3. monitor for s/s of allergic response
Interactions with cefazolin/Ancef?
can interfere with some tests
Action of vancomycin?
- 1. alters cell wall permeability -> inhibits cell wall synth
- 2. inhibits RNA synth
Why is vancomycin usually used as a last resort?
strong and toxic
Use for vancomycin?
serious infections when other ABX have failed
Prob with vancomycin?
vancomycin resistance is increasing
Vancomycin is limited by?
its ability to produce toxic effects
3 potential serious AE of vancomycin therapy?
- 1. ototoxicity
- 2. nephrotoxicity
- 3. red-man syndrome
S/S of ototoxicity?
tinnitus, decreased hearing
Monitoring for nephrotoxicity in vancomycin pt?
monitor I&O & creatinine
What causes red-man syndrome?
anaphylactoid reaction caused by histamine release when the med is given too fast
diffuse redness & blisters
Nursing responsibilities when admin vancomycin IV?
- 1. admin slowly over at least 60 minutes (more if possible)
- 2. use the largest access/vein possible
- 3. Avoid extravasation
Why does vancomycin need to admin very slowly and monitored closely for extravasation?
it is very caustic
3 assessments/monitoring for vancomycin?
- 1. monitor peak and trough levels
- 2. monitor I&O & creatinine for renal failure
- 3. assess for s/s of ototoxicity
6 antibiotic types that affect protein synthesis?
- 1. aminoglycosides
- 2. lincosamides
- 3. oxazolidinones
- 4. streptogramins
- 5. tetracyclines
- 6. macrolides
- 7. miscellaneous
2 types of action of antibiotics that affect protein synthesis?
bactericidal or bacteriostatic
Antibiotics that affect protein synthesis are used for what type of infections?
(aminoglycosides, lincosamides, oxazoladinones, streptogramins, tetracyclines, miscellaneous)
reserved for more serious infections
______ may occur with the use of antibiotics that affect protein synthesis.
(aminoglycosides, lincosamides, oxazalidinones, streptogramins, tetracyclines, and misc.)
Action of aminoglycosides?
- enter bacterial cell wall -> bind to ribosomes -> prod. wrong amino acids ->
- 1. prevents bacterial reproduction
- 2. weakens the cell wall
- 3. cell wall rupture & death
Resistance that may occur with aminoglycosides like gentamicin?
many bacteria are resistant to aminoglycosides entering their cell walls
Why is gentamicin often given with other meds?
increase effectiveness or allow it to enter cell walls
lowest conc. in pt blood
should be drawn 30 minutes before the next dose
drug is at its highest conc.
draw 45 min (IV) to 1h (IM) after admin of a med
3 AE of gentamicin?
- 1. ototoxicity
- 2. nephrotoxicity
- 3. neurotoxicity
5 things to assess/monitor with admin of gentamicin?
- 1. hearing
- 2. I&O, creatinine, and BUN
- 3. neurovascular assessments
- 4. draw peak & trough levels
Why do gentamicin levels need to be monitored closely?
has a narrow therapeutic index
Important consideration with lincosamide?
Action of clindomycin?
enters cell -> binds to ribosomes -> suppresses protein synth -> cell death
Use for clindamycin?
serious to life-threatening infections
ABX group that should always be taken with food?
When a drug works by inhibiting protein synthesis it will usually be used for _____ infections.
Story for clindamycin?
Clinda loves Zelda. She is Link from Zelda (lincosamide). All she does is play vid games and eat. She eats so much she gets GI upset that causes pseudomembranous colitis, and is so sedentary that her blood has pooled (blood abnormalities).
Clindamycin common AE?
Serious AE of clindamycin?
- pseudomembranous colitis
- blood abnormalities
Type of infections Tx by clindamycin?
S/S of pseudomembranous colitis?
- abd cramps/tenderness
Remembering prototype for macrolides?
macrolide - macro means big and ends with E
big E - erythromycin
Action of macrolides/erythromycin?
inhibits RNA-dependent protein synth at chain elongation step -> prevent reproduction
Interaction with macrolides/erythromycin?
absorption is diminished by food, dairy, & antacids
decrease effects of drug
Which ABX causes azotemia?
Contraindication with erythromycin?
Common AE of erythromycin?
GI distress even when admin IV
Nursing intervention to decrease GI AE in erythromycin?
small frequent meals, but remember to time them so they are not close to med admin b/c decrease med effects
4 serious AE of erythromycin?
- 1. hepatotoxicity
- 2. pseudomembranous colitis
- 3. QT prolongation
- 4. ventricular tachycardia
Monitoring/assessment for pt on erythromycin?
- 1. monitor liver enzymes
- 2. have on telemetry if poss. or monitor frequently & educate pt what to look for
- 3. monitor for s/s of pseudomembranous colitis
- 4. HR for tachycardia
Admin of erythromycin IV?
admin very slowly to decrease irritation to the veins - at least 60 minutes
oxazolididones - zyvox
oxazolidinones/zyvox were the first new type of drugs dev to treat ____ & _____.
Diff b/t zyvox and other protein inhibiting ABX?
blocks early stages of protein synth - may prevent the dev of resistance & cross resistance
2 actions of zyvox?
- 1. inhibits protein synth in bacteria
- 2. nonselective MAOI actions
Interactions with Zyvox?
has serious drug & food interactions r/t MAOI actions:
Avoid: tyramine, alcohol, & caffeine
Common AE of Zyvox?
2 serious AE of Zyvox?
- 1. thrombocytopenia
- 2. pseudomembranous colitis
guts someone (pseudomembranous colitis) & they bleed so much they don't have platelets
What needs to be done if pt is an alcoholic and needs to take zyvox?
will need to call MD to see what to do r/t concern for W/D if don't take alcohol
can't take alcohol with zyvox
What are streptogramins designed to Tx?
Assessment that should be done prior to admin of zyvox?
assess platelets - if low don't give
Action of Synercid/streptogramins?
irreversibly blocks ribosome functioning -> inhibits protein synth
Use for Synercid/streptogramins?
Tx superbugs: VRE & MRSA
What may be required prior to admin of Synercid/streptogramins?
may need approval from infectious disease department before using
2 things that occur as ABX get more powerful?
have more AE & get more expensive
Why do streptogramins/Synercid have increased risk for drug interactions?
potent inhibitor of P450
3 common AE of Synercid?
- 1. injection site reaction/pain
- 2. thrombophlebitis
- 3. NVD
Serious AE of Syndercid?
hepatotoxicity - very hepatotoxic
synercid - sinner drink too much and damage their liver
2 things to do prior to the admin of Synercid?
- 1. check C&S
- 2. assess liver LFT & bilirubin
Testing with Syndercid?
need bilirubin and LFT twice in first week then weekly
Considerations for admin of Synercid?
- 1. flush IV before & after admin with D5W - interacts with saline & heparin
- 2. prefer central line for admin
- 3. if no central line dilute in 250mL D5W & infuse over 1 h in largest vein possible
Action of tetracyclines?
retards bacterial growth by inhibiting protein synth
3 uses for tetracyclines?
- 1. serious infections when penicillin cannot be used: lyme disease, rocky mnt. spotted fever
- 2. acne vulgaris
- 3. chlamydia & other STD's
Problem with frequent use of tetracycline?
resistance is occurring
Interaction with tetracycline?
dairy products, vitamins/supplements, & antacids interfere with the absorption
Contraindications for tetracycline?
- 1. pregnant/breast feeding
- 2. CH < 8
Why is tetracycline contraindicated in pregnancy?
causes skel retardation
3 most common adverse effects with tetracycline?
- 1. GI distress: NVD & heartburn
- 2. photosensitivity
- 3. tooth discoloration
2 serious AE of tetracycline?
- 1. skel. retardation in infants
- 2. azotemia
What is azotemia?
- high levels of nitrogenous wastes build up (urea, creatinine)
- decreased UO & LOC, increased HR, dry mouth, edema, ortho BP, uremic frost
monitor I&O & creatinine
Prototype misc. antibiotic affecting protein synth? (2)
chloramphenical & fluoroquinolones
What type of ABX is chloramphenicol?
What type of microbe does it work on?
true broad spectrum ABX
gram positive & gram negative
What type of infections is chloramphenicol used for?
serious infections: meningitis, brain abscesses, rickettsial infections, and acute typhoid fever
Black Box warning with chloramphenicol?
What are rickettsial infections?
infections caused by bacteria from ticks: rocky mnt spotted fever, lyme disease, ricketsia ricketsii, etc
Contraindications for chloramphenicol?
hypersensitivity & breastfeeding
Common AE of chloramphenicol?
Serious AE of chloramphenicol?
- 1. blood dyscrasias
- 2. grey-baby syndrome
amphenicol - bleaches babies & blood
What causes grey-baby syndrome to occur with chloramphenicol therapy?
What babies are most at risk for grey-baby syndrome?
preemies and/or underdeveloped liver
S/S of grey-baby syndrome?
grey/blue skin, feeding probs
Admin of oral chloramphenicol?
give on empty stomach
Nursing interventions with admin of chloramphenicol?
- 1. monitor peak, trough, and levels
- 2. teach pt s/s of bone marrow suppression/blood dyscrasias & importance of telling MD immediately
- 3. monitor clotting & CBC
Fluoroquinolones end with ______.
Action of ciprofloxacin?
inhibits DNA gyrase (enzyme needed for bacterial DNA replication)
human DNA is not affected b/c uses diff enzyme
What type of bacteria is ciprofloxacin most effective against?
gram negative aerobes
Resistance to ciprofloxacin?
some has developed
Common AE of ciprofloxacin?
- 1. a lot of GI probs
- 2. secondary infection by candida
Why do a lot of secondary infection with candida occur with ciprofloxacin?
b/c normal flora in the body are mostly gram neg. & ciprofloxacin is effective against them
2 types of infections ciprofloxacin is used for?
Serious AE of ciprofloxacin?
- 1. arthropathy (joint disease)
- 2. achilles tendon rupture
athletes are hard on their joints and may rupture their achilles tendon
Why is ciprofloxacin not usually given to CH?
b/c arthropathy AE is more common in ppl under 18 years old
Ciprofloxacin during pregnancy?
do not give - increased risk for arthropathy
IV admin of ciprofloxacin?
- 1. admin slowly over at least 60 minutes
- 2. use large vein
reduces venous irritation
Intervention for ciprofloxacin bad GI AE?
eat small frequent meals
Prototype cyclic lipopeptide?
complicated skin infections like staph infections
Type of microbe affected by daptomycin/Cubicin?
antibiotic-resistant gram positive
resistant to penicillins which also work on gram positive
Common AE of daptomycin/Cubicin?
Serious adverse effects of daptomycin/Cubicin?
myopathy - muscle pain/damage
What needs to be done prior to the admin of daptomycin/Cubicin?
Admin of IV daptomycin/Cubicin?
admin over at least 30 minutes to mnimize AE
Monitoring with daptomycin/Cubicin?
monitor weekly CK
CK - creatinine kinase - will increase with muscle damage
3 ABX that should not be taken during pregnancy?
CQT's = No OB's
chloramphenicol, tetracycline, quinolones
Pt education for daptomycin/Cubicin?
notify MD if have diarrhea, muscle pain, or tingling
5 drugs used to Tx UTI's?
- 1. cephalosporins
- 2. fluoroquinolones
- 3. penicillins
- 4. tetracycline
- 5. bactrim
Abbreviations for bactrim?
SMZ-TMP or TMP-SMZ
Action of bactrim?
interferes with the synthesis of FA needed for synth of RNA/DNA & proteins -> prevents formation of new bacteria
Contraindication for bactrim
folate deficiency disorders
Uses for bactrim? (4)
- 1. UTI
- 2. resp infections - pneumocystis carinii pneumonia in AIDS pt
- 3. GI infection
- 4. STI's
Common AE of bactrim?
What can cause increased risk for AE in bactrim?
immunocompromised pt such as AIDS pt
5 serious AE of bactrim?
- 1. renal damage caused by crystalluria
- 2. allergic reactions
- 3. Stevens Johnson Syndrome
- 4. blood dyscrasias
- 5. photosensitivity
4 nursing considerations for admin of bactrim?
- 1. monitor immunocompromised closely r/t increased risk for AE
- 2. give with food
- 3. increase fluid intake to at least 1.5L/day unless CI to decrease crystalluria
- 4. avoid ETOH
Monitoring for pt taking bactrim?
- 1. I&O & creatinine
- 2. CBC
- 3. s/s of stevens johnson/hypersensitivity
Teaching for pt taking bactrim?
2 urinary antiseptic drugs?
- 1. methanamine
- 2. nitrofurantoin/Macrodantin/Macrobid
Action of urinary antiseptic drugs?
work locally in the urinary tract
Advantage of metanamine & nitrofurantoin?
do not achieve high serum levels b/c work in urinary tract -> have few systemic effects
Drug that is a urinary analgesic?
Action of phenazopyridine/Pyridium?
no antibacterial activity
relieves pain, burning, frequency, & urgency r/t irritation of the urinary tract due to infection
Teaching for pt taking phenazopyridine/Pyridium?
discolors urine orange/red
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