Antibiotics Flashcards
MRSA
Methicillin Resistant Staphylococcus Aereus
VRE
Vancomycin Resistant Enterococcus
ESBL
Extended-Spectrum Beta-lactamases
KPC
Klebsiella Pnuemonia Carbapenemase
trough 1 hr before dose
peak 1 hr after dose
Vancomycin
Temp above 101 degrees or 38 degrees C with chills and malaise are indicators of a systemic infection
-fever may occur without infection
-Infection can be present without fever
-Older adults whose baseline temp is 1-2 degrees lower, may have a fever at 98.6/37
-Hyperthermia is normal immune response that can help destroy the pathogen.
-
Infection
Acetaminophen and Ibuprofen are common.
- These drugs mask fever and make monitoring the course of the illness difficult
- Give if uncomfortable or if fever presents risk (102/38.9)
- heart failure, febrile seizures or head injury.
- Side effects; sweating, drop in BP, return of fever.
- Increase fluid intake and regularly schedule meds.
Anti-pyretics for infection
Cover patient with sheet only. Tepid sponge bath Encourage PO fluids/IV fluids *hyperdynamic state-dehydrate only *monitor for decrease skin turgor, dry mucous membranes, confusion, and increased thirst. Hypothermia blanket; monitor closely *shivering increases temp *setting of blanket? -No fans; disperse airborne/droplet pathogens
Fever Treatment/infection
Risk for social isolation
- The pathogen, not the patient, requires precaution!
- Explain disease/transmission/treatment plan
- Precautions in the home
- Wear gloves when changing dressing
- Wash soiled clothing with disinfectant/bleach
- Complete entire course of antimicrobial drug therapy
- When to call the Dr.
- use another form of birth control when using ABX
Health teaching for infection
- Inhibit cell wall synthesis
- inhibit protein synthesis
- disrupt cell membranes (alter membrane permeability)
- interfere with nucleic acid synthesis/cellular metabolism
- prevent synthesis of folic acid (need folic acid to replicate and grow)
5 Major Mechanisms of activity of Antimicrobials
Bacteriostatic
*antimicrobial drug inhibits the growth of the organism
*leaves host immune system to destroy it
Examples: Tetracyclines, erythromycin
Bactericidal
*antimicrobial drug directly kills the organism
*Immune system is not involved
Examples: Penicillins, cephalosporins aminoglycosides
Antimicrobial drugs classifications
- Microbial resistance; MDRO’s
- Identification of causative organism
- Site of infection
- Interaction with other drugs
- clinical status and behavior of the patient
- Pharmacological properties of the drug
- Superinfections
- Vaginal yeast infection
- Pseudomembraneous colitis, Clostridium Difficile
Factors that affect the Outcome of Antimicrobial Therapy
Assess drug allergies; renal, liver and cardiac function, and other labs.
- Obtain thorough patient health history, including immune status
- Assess for conditions that may be contraindications or indicate cautious use.
- G6PD Deficiency; (glucose-6-phosphate dehydrogenase)-may cause hemolysis
- Slow Acetylation; metabolize some drugs slowly
- Assess for potential food and drug interactions.
- Instruct patients to take abx exactly as prescribed and for the length of time prescribed; they should not stop taking the medication early when they feel better.
- Assess for s/s of superinfection: fever, perineal itching, cough, lethargy, or any unusual discharge.
- Ea. class of Abx has specific adverse effects & drug interactions that must be carefully assessed and monitored.
- The most common Adverse effects of ABX:
- nausea
- vomiting
- diarrhea
- All oral Abx are absorbed better if taken with at least 6 to 8 oz. of h2o.
- If on birth control use back up method.
Nursing Implications:
What to know before giving ABX’s??
Empiric therapy:
- Get cultures if possible prior to med delivery
- Usually broad spectrum ATB; Use EVB to determine which drug to start first.
Pharmacology Overview:
Empiric therapy
Definitive therapy:
*Tailored to results of cultures; specific drug.
Pharmacology Overview:
Definitive therapy
Prophylactic therapy:
- Preventative infection
- National Performance Improvement Project
- SCIP Surgical Care Improvement Project
- Administration of ABX 30 mins prior to surgical incision.
Pharmacology Overview:
Prophylactic Therapy
- Broad class of AB four subclasses: penicillins, cephalosporins, carbapenems and monobactams.
- Named because of beta-lactam ring that is part of chemical structure
- Subclasses share common structure and mechanism of action-they inhibit synthesis of bacterial peptidoglycan cell wall
- Bacterial strains produce the enzyme beta-lactamas
- provides a mechanism of bacterial resistance to antibiotics and breaks down Carbon & Nitrogen in structure of beta-lactam ring
- all beta-lactam drugs then lose antibacterial efficacy so beta-lactamase inhibitors are added to several penicillins abx to make the drug more powerful against Beta-lactamase producing strains.
beta-lactam antibiotic
Natural Penicillin; only ones in clinical use
- penicillin G; inj, IV
- penicillin V; PO (tab, liquid)
Penicillin:
Natural Penicillin
Penicillinase; resistant drugs; stable against hydrolysis by most staphylococcal penicillinase
- cloxacillin
- dicloxacillin
- nafcillin
- oxacillin
Penicillin:
Penicillinase
Aminopenicillin; work better on gram (-) bacteria;
- amoxicillin
- ampicillin
Penicillin:
Aminopenicillin
Extended spectrum drugs; wider spectrum, gram (+), gram (-), anerobic. Used to treat hospital acquired infections like pneumonia and sepsis.
- piperacillin
- ticeracillin
- carbenicillin
- piperacillin/tazobactam
Penicillin:
Extended spectrum drugs
Action: Inhibits bacteria cell wall synthesis. Able to penetrate cell wall to breakdown the cell.
Use: Prevention and treatment of gram (+) bugs.
ie. *streptococcus
*enterococcus
*staphylococcus
Note; little if any ability to kill gram (-)/not all penicillin meds end in -cillin
Adverse Effects: urticarial (hives) Pruitus (itching) Angioedema Steven Johnson's syndrome Severe reaction with IM or IV
Drug Interactions:
- Warfarin-decrease Vitamin K, enhanced anticoagulant effects.
- methotrexate-decreased renal elimination of methotrexate, increasing levels in blood.
- NSAIDS; competes for protein binding, possible toxicity levels.
- Oral contraceptives-decreases effectiveness
Route: PO, IM, IV
Duration of action: 4 to 8 hours depending on route
Dose-dependent on weight and route
Penicillin
- Carbapenems*
- must be infused over 60 mins
- used for UTI, intra-abdominal bacterial infections, pneumonia, pelvic infections, pyelonephritis
- unlike many of the penicillins and cephalosporins, imipenem/Cilastatin is very resistant to antibiotic-inhibiting actions of betalactamases.
ie. Imipenem-Cilastatin (primaxin)
Carbapenems
**Therapeutic class: Anti-infectives
**Pharm class: carbapenems
**Action: binds to penicillin-binding proteins against bacteria. Used against gram pos and neg aerobic and anaerobic bacteria.
**Route/frequency/dose: IV 250-500 mg q 6-8hr. IM 500-750 mg q12
**Side effects: seizures, diarrhea, nausea, vomiting, rash, pseudomembranous colitis
**Contraindications: Cross-sensitivity may occur with penicillins and cephalosporins. Use cautiously in renal impairment, older patients, patients pregnant or breast feeding.
**Nursing Implications: Labs; BUN, AST, ALT, LDH, serum alkaline phosphatase, bilirubin, and Creatinine may be transiently increased.
-H & H concentrations may be decreased.
-Assess patient for infection (VS, appearance of wound, sputum, urine, and stool; WBC) at beginning of and throughout therapy.
Obtain a hx before initiating therapy to determine previous use of and reactions to penicillins. Persons with a neg. hx of penicillin sensitivity may still have an allergic reaction.
-Obtain specimen of cultures and sensitivity before initiating therapy. First dose may be given before receiving results
Carbapenems
Therap. class; anti-infectives
Pharm class: carbapenems
Action: only Carbapenem used to treat against bacterial meningitis. Somewhat less active against gram pos and more active against gram neg, equally with p. aeruginosa. Binds to bacterial cell wall, resulting in cell death. Meropenem resists the actions of many enzymes that degrade most other penicillins and penicillin-like anti-infectives.
Meropenem (merrem)
Route IV
Rapid onset
end of infusion 8hr duration
**Side effects: Seizures, apnea, pseudomembranous colitis, diarrhea, glossitis, (increase in children), nausea, thrush (increase in children), vomiting
**Contraindications: Use cautiously in renal impairment, older patients, patients pregnant or breast feeding
**nursing Implications: Assess for infection, (VS, appearance of wound, sputum, urine and stool; WBC) at beginning of and throughout therapy. Obtain a hx before initiating therapy to determine previous use of and reactions to penicillins. Persons with a negative hx of penicillin sensitivity may still have an allergic response.
-Obtain specimens for culture and sensitivity prior to initiation therapy.
-First dose my be given before receiving results. observe for signs of anaphylaxis!
-Assess injection site for phlebitis, pain and swelling periodically during administration.
-Labs to consider: Monitor hematologic, hepatic, and renal functions periodically. BUN, AST, ALT, LDH, serum alkaline phosphatase, bilirubin, and creatinine. (increase)
H & H concentrations may be decreased.
Meropenem (merrem)
- Aminoglycosides should be taken exactly as prescribed with adequate hydration.
- Encourage fluid intake up to 3000ml/daily
- Report changes in hearing, tinnitus
- Report persistent nausea, vomiting and vertigo
Patient Teaching
Aminoglycosides
- Nephrotoxicity
2. Ototoxicity
Side effects of Aminoglycosides
- Renal function during therapy
- BUN and creatinine
- Perform baseline hearing test
- Assess vestibular function test
Assess; Aminoglycosides
Shorter duration of action 8-12 hrs.
Used for Gentamycin or neomycin resistance.
Amikacin (Aminoglycosides)
Duration of action-24 hrs
Broad spectrum, most commonly used
Gentamycin (Aminoglycosides)
Given orally
Neomycin (Aminoglycosides)
Used to treat pulmonary infections
Tobramycin (Aminoglycosides)
Destroys bacteria by altering their DNA by interfering with bacterial enzymes. Kills susceptible strains of mostly gram negative and some gram positive organisms.
Action of Quinolones
- Wide spectrum, suitable for treating complicated UTI’s
- Commonly used to treat respiratory, skin, GI, and bone and joint infections.
- Bacterial resistance from Pseudomonas aeruginosa, S. aureus, Pneumoncoccus spp., enterococcus spp., and E. coli
Indications of Quinolones
-Only true contraindication is known drug allergy
Contraindication for Quinolones
CNS; headache, dizziness, insomnia, depression, restlessness, convulsions
GI; Nausea, constipation, increased AST and ALT levels, flatulence, heartburn, vomiting, diarrhea, oral candidiasis, dysphagia
Integumentary; Rash, pruritus, urticaria, flushing
Other; Ruptured tendons and tendonitis, fever, chills, blurred vision, tinnitus
Adverse Effects: Quinolones
Antacids, Calcium, Magnesium, Iron, and Zinc causes reduction in the oral absorption of quinolones.
-Dairy products also reduce oral absorption.
Pt’s need to take interacting drugs 1 hour before or 1 hour after taking quinolones.
Interactions: Quinolones
Levofloxacin (Leaquin)
Pharm Class: Fluoroquinolone
Common Indications: Respiratory and Urinary Tract Infections. Prophylaxis in various transrectal and transurethral prostate surgical procedures.
Usual Dosage Range: IV/PO; 250-750 mg once daily
*One of the most widely used quinolones
*Broad spectrum of activity, but has the advantage of once daily dosing
*Available in both oral and injectable forms
*Comparable to that of Ciprofloxacin with better gram-positive coverage.
Levofloxacin (Levaquin)
Ciprofloxacin (Cipro)
Pharmacological Class: Fluoroquinolone
Common Indications: Anthrax, respiratory, skin, urinary tract, prostate, intra-abdominal GI, bone and joint infections, Typhoid fever, selected nosocomial pneumonia
**Usual Dose Range: Adult IV; 200-400 mg q12
PO 250-750 mg q8-12
*Compared to Levofloxacin, Ciprofloxacin is capable of killing a wide range of gram-negative bacteria.
Ciprofloxacin (Cipro)
- Antibiotic of choice for MRSA and gram + bacteria.
- Not active against gram -, fungi or yeast.
- Oral vancomycin is good for C. diff, and S. enterocolitis
- Parenteral use is indicated for treatment of bone and joint infections and bacterial blood stream infections caused by Staph.
- Increased resistance of Vancomycin with patient that has enterococcus infections.
Vancomycin
Hypersensitivity
Cautions: Preexisting renal dysfunction & Hearing loss in elderly and neonates
-Has low therapeutic index
*Too low (less than 5 mcg/ml) it doesn’t work
*Too high (more than 50 mcg/ml) toxicity occurs
-Can cause neuromuscular blockage
-Can cause red man syndrome; flushing, itching of head, face, neck and upper trunk.
(Caused when infusion is too fast, Rapid infusion also causes hypotension)
-Peak level is 18-50 mcg/ml
*Draw 1 hr. after administration
-Trough level is 10-20 mcg/ml
*Draw 1 hour before administration
Vancomycin Contraindications
Currently only drug in classification lipopeptides
- Method of action is not completely known
- Binds to gram + cells in a calcium dependent process
- Used to treat complicated skin and soft tissue infections- MRSA and VRE
- Contraindicated in cases of known drug allergies
- Only available in parenteral form
- Adverse reactions are; hypotension, hypertension, dizziness, headache, rash, GI discomfort, elevated liver enzyme, dyspnea, fungal infection, site irritation.
- Drug interaction aren’t defined yet
- If given with statin drugs can cause myopathy.
Daptomycin
Treats Acne, bacterial infection of the vagina, taxoplasms, staph infections of the bone, skin, respiratory, and GU tract.
-May prevent bacterial infection of the heart.
-Treats aneorobic infections, streptacoccal.
Drug class Lincosamides
Pregnancy Risk Cat. B
Bacterocidal/bacteriostatic
IV/PO 300-900 mg bud qid
Contraindicated in ulcerative Colitis, enteritis, inhibits protein synthesis in bacteria.
Clindamycin
Drug class; Lincosamides
Drug class: oxazolides
Drug: linezolid (zyvox); inhibits bacterial protein synthesis, used to treat hospital acquired pneumonia and skin infections caused by MRSA and gram positive infections in infants and children.
**Adverse effect: headache, nausea, vomiting, diarrhea, decreased platelet count
**Contraindicated: hypersensitivity
***Route; PO or IV
Linezolid (zyvox)
Drug class: oxazolides
-Used to treat or prevent infections caused by bacteria.
-Frequently used to treat UTI’s caused by gram neg. organisms and staphylococcus aureus.
Also intra-abdominal and gynecological infection.
Preg Cat. B
Interfers with microbial DNA synthesis
-IV/PO 250-500 mg q 6-12 hrs
-dizziness, headache, GI discomfort, nasal congestion, reversible neutropenia, thrombocytopenia
-avoid alcohol 24 hrs before starting this medication and 36 hrs. after finishing the medication.
Metronidazole (Flagyl)
nitrofurantoin
Trade name macrodantin
Used for UTI caused by E. coli, S. aureus, klebsiella, and enterobacter.
Interferes with bacterial enzyme that metabolises carbohydrates.
Contraindicated in drug allergy and renal failure
PO administration only
**Adverse Effects; GI discomfort, dizziness, headache, skin reactions, blood dyscrasias, ECG changes, possible irreversible neuropathy and hepatotoxicity.
**Nursing Implications: assess renal and liver function, sensory and motor function, skin for turgor, intactness, and rash. Decrease dose with renal impairment.
nitrofurantoin (Macrodantin)
Encourage fluids up to 3, 000ml/day
Adverse effects: risk of hearing loss
Report HA, nausea, vertigo
Signs of superinfection; diarrhea, vaginal discharge, stomatitis, cough, loose/foul smelling stools
Aminoglycosides
Avoid use of tanning beds, use sunscreen & sunglasses
Report HA, dizziness, restlessness, diarrhea, vomiting, and thrush
Drug Interactions: calcium, magnesium, nitrofurantoin, oral anticoagulants, antacids, iron, sucralfate, & zinc preparations
Take exactly as ordered
Quinolones
Avoid topical forms near eye or near any abraded areas to avoid irritation.
If vaginal form used, don’t engage in sexual intercourse
If it gets into eyes, flush eyes with copious amounts of cool tap water
Clindamycin
Avoid tyramine-containing foods (red wines, aged cheeses)
Report: abdominal pain, diarrhea, worsening of signs and symptoms, fever
Linezoid
Report abdominal cramping, dizziness, jaundice, severe skin reactions
Nitrofurantoin
Avoid alcohol to avoid risk of severe vomiting
Metronidazole
Report changes in hearing, such as ringing or feeling of fullness in the ears
Report: N/V, unsteady gait, dizziness, generalized tingling, chills, fever, rash, hives
Monitor serum levels to prevent toxicity: trough & peak
Vancomycin
- Gather data r/t hypersensitivity or allergy to abx
- Pt. age, weight, VS & body temp
- Labs, liver, kidney, and cardiac function
- Culture & sensitivity
- CBC
- Assess bowel sounds & patterns b/c of potential GI affects from Abx
- Assess for any drug interactions and get complete list of current meds
- Neurological assessment bc of possible CNS side affects
- Cultural assessment r/t any at home remedies or OTC meds
General ABX Assessment
Check allergies to sulfa-type drugs, anti-diabetic drugs &/or thiazide diuretics.
Thorough skin assessment bc of Stevens Johnson syndrome side effects
Check RBC for drug related anemia
Need to be avoided in patients with G6PD and slow acetylation .Encourage fluids (2000-3000 ml/24 hr) to prevent drug-related crystalluria.**
Sulfonamides
Assess for allergy to Cephalosporin and/or aspirin
Assess for asthma
Monitor Na & K levels in pt with electrolyte disorders
Penicillins
Assess for allergy to penicillin
Cephalosporins
Assess pt for hx of seizures
Carbapenems
Baseline hearing status; drug related induced hearing loss and tinnitus
Liver function or hx of liver disease
Possible toxicity with Warfarin, Digoxin, or Theophylline
Macrolides
- Use cautiously in children under 8 years old, may cause permanent mottling and discoloration of teeth.
- Contraindicated for use in pregnant women.
- Do not use with antacids or antidiarrheal drugs, dairy products, calcium, enteral feedings and iron preparations. May lead to reduced absorption of antibiotic.
Tetracyclines
This ABX can kill off the natural flora in the GI track causing an overgrowth of C. diff. Taking a probiotic is recommended.
Penicillin
Therapeutic effects of ABX include a decrease in the signs and symptoms of the infection, a return to normal vs, including temp, negative results on culture and sensitivity tests: normal results for CBC, and improved appetite, energy level, and sense of well being.
Evaluation of ABX therapeutic effects
Classification: Penicillin
Drugs; amoxicillin, ampicillin, ticarcillin, piperacillin
Treats: infections, UTI, pneumonia
Side-effects: Steven Johnson, N&V, stomach pain, constipation, diarrhea, anxiety
Nursing Implications: watch for bleeding/clotting
Education: take drug for entire time, make birth control less effective, be cautious if on blood thinners, diarrhea is common side effect.
Treatment is usually 7-10 days
Penicillin
ABX; Bacteriostatic or Bactericidal
- mostly work by inhibiting bacterial cell wall synthesis
- Common adverse effects of Abx, include N&V, diarrhea
- Advise pt amount/length of time prescribed.
- Ea. class of Abx have different contraindications, specific cautions, drug interactions, and adverse effects.
- Superinfections may arise during treatment. s/s, fever, perineal itching, oral lesions, vaginal irritation, and discharge, cough & lethargy.
Key Points to know ABX
- Provide client with a list of foods and bevs that interact with ABx
- Report any severe adverse effects
- Take probiotics to help promote natural flora to prevent superinfections
- Use back up birth control; not be as effective
- Wear medical bracelet if any drug allergies
- Drink plenty of fluids, esp. when taking sulfonamides to decrease GI adverse effects.
- Take penicillin medications exactly as prescribed and in full duration
- Avoid Caffeine, citrus fruits, colas, fruit juices and tomato juice; decreases effectiveness of ABX
- If taking Cephalosporins, report any GI upset; Avoid alcohol
- If on Tetracyclines avoid exposure to sun or tanning beds. Use sunscreen.
- For Macrolids, take as directed, check for any interactions, with other drugs, esp. with erythromycin. Know proper dosage and instructions.
Teaching for ABX
- Classification; Tetracycline
- Class: Broad Spectrum ABX
- *Natural Types: demeclocycline; PO & oxyletracycline; PO
- *Synthetic Types: doxycycline; IV or PO & minocycline; PO & tigecycline; IV only (newest)
- **Mechanism: inhibits growth and kills a wide range of bacteria.
- **Commonly used for: Lymes disease; PID, Syphilis; Acne, Cholera, H. pylori, Rickettsia (Not used for Gonorrhea due to resistance)
- *Adverse Effects: Thrombocytopenia, hemolytic anemia, increase in BUN, exacerbation of lupus, permanent discoloration of teeth (do not give to children under 8); not recommended during pregnancy.
- *Avoid: milk, antacids, iron salts
Tetracycline
Broad class of ABX includes: Penicillin Derivatives Cephalosporins Carbapenems Monobactams
Beta Lactams
Aztreolam (Azactam)
- the only one developed
- synthetic beta lactam
- primarily active against aerobic gram negative (E. Coli, Klebsiella, Pseudomonas)
- bacteriocidal
- Treatment of moderately severe systemic infections & UTI’s
- Combined with other abx for treating intrabdominal & gynecologic infections
Monobactams
Only available in injectable form (IV, IM) Contradicted if known drug allergy Adverse effects: Rash N & V Diarrhea
Monobactams
- A natural bactericidal ABX
- destroys bacteria by binding to the bacterial cell wall, producing immediate inhibition of cell wall synthesis & death
- antibiotic of choice for the treatment of MRSA infection & infections caused by many other gram-positive bacteria
- is Not active against gram-negative bacteria, fungi or yeast
- Oral vancomycin is indicated for the treatment of ABX-induced colitis (C.diff) & for the treatment of staphylococcal enterocolitis
- Parenteral form is indicated for the treatment of bone & joint infections & bacterial bloodstream infections caused by Staphylococcus
- resistance to vancomycin has been noted with increasing frequency in patients with infections caused by Enterococcus organisms
vancomycin
- patients with a known hypersensitivity to it
- used with caution in those with preexisting renal dysfunction or hearing loss, as well as in elderly patients & neonates
Contraindications for vancomycin
- too low of levels, dosage may be subtherapeutic with reduced antibacterial efficacy
- too high of levels, toxicities may result
Specific drug levels; vancomycin
- ototoxicity (hearing loss)
- nephrotoxicity (kidney damage)
* **Vancomycin can also cause additive neuromuscular blocking effects in patients receiving neuromuscular blockers.
Two most severe toxicities; vancomycin
Red Man Syndrome (characterized by flushing &/or itching of the head, face, neck & upper trunk area);
Rapid infusions may also cause hypotension
Adverse Effects for vancomycin
