Class 12: Antibiotic therapy & pharmacology + anti-inflammatory medication Flashcards
If cultures are not taken before administering antibiotics..
They can mislead the results of cultured specimens and prolong therapy
Gram-negative infections are…
Generally harder to treat because of the more complex cell walls
Gram-stain classification
-Purple stains= gram-positive and red stains are gram-negative
-Helps practioners determine the most suitable antibiotics
Superinfections
-A complex infection that can occur during or after antimicrobial treatment for another infection
-Can occur when antibiotic therapy is sub-therapeutic
-In antibiotic therapy, healthy gut flora can be killed allowing other types of bacteria to take over
Examples of superinfections
MRSA, VRE and C. Diff.
Sub-therapeutic therapy occurs when…
S&S do not seem to be improving
Sub-therapeutic therapy can be d/t
Incorrect route, inadequate drainage of an abscess, poor drug penetration, insufficient drug levels or bacterial resistance
Types of antibiotics
Sulfonamides, macrolides, B-lactam antibiotics, ahminoglycosides, tetracyclines, fluoroquinolones and miscellaneous antibiotics
B-lactam antibiotics
-PMCC
-Penicillins, monobactams, cephalosporins and carbapenems
Miscellaneous antibiotics
Vancomycin, clindamycin and metronidazole
4 main sites of action for antibiotic therapy
-Interfere with cell wall or protein synthesis
-Interfere with DNA replication & RNA synthesis
-Interfere with bacteria cell metabolism
Bactericidal antibiotics does what and includes which antibiotics?
-Kills bacteria
-AdoubleCtripleM,PFV
-Aminoglycosides, cephalosporins, carbapenems, macrolides, monobactams, metronidazole, penicillins, fluoroquinolones and vancomycin
Bacteriostatic antibiotics
-Do not kill, only inhibits growth
-MCATS
-Macrolides, clindamyscin, aminoglycosides, tetracyclines and sulfanomides
[ ] means
Concentration
Sulfonamide general information
-First drugs ever used as antibiotics.
-Combined with trimethoprim for synergistic effects
Sulfonamide indications
-Broad spectrum antibacterial activity against gram-positive & gram-negative bacteria
-Commonly used for UTIs, respiratory tract infections and general prophylaxis
Sulfonamide MOA
-Bacteriostatic antibiotics
-Inhibit bacteria growth rather than destroy it by affecting its metabolism (folic acid)
Sulfonamide adverse effects
-“Sulfa allergy”, starts with a fever then can proceed to a rash
-Photosensitivity; exposure to sunlight causes a rash
-Anemias, skin reactions, Stevens-Johnson syndrome, pancreatitis, convulsions, headaches, crystalluria and toxic nephrosis
Sulfonamide contraindications/drug interactions
-Sulfonylureas for DM
-Cyclosporin inhibits immunosupressant effects
-Phenytoin can increase the risk for toxicity
-Warfarin increases the anticoagulant effects
-Pregnant woman, geriatrics and children under 2
Sulfonamide nursing implications
-Severe allergies? Hx of renal disease? Therapeutic response?
-Monitor skin & bowel function
-Re-evaluate lab work
Macrolide general information
-Became popular in the 1950’s with the introduction of erythromycin
-Longer duration resulting in fewer required doses
-Use if pt is allergic to a B-lactam
Macrolide indications
-Respiratory tract infections
-Skin and soft tissue infections
-STIs
Macrolide MOA
-Bacteriostatic antibiotic but in high enough [ ]’s it can be considered bactericidal in nature
-Inhibits bacterial protein synthesis (binds to the ribosomes 50S subunit inside of the bacteria cell causing them to eventually die)
Macrolide adverse effects
GI upset is the most common
Macrolide contraindications
Decrease the efficacy of oral contraceptives, pregnanct women & in geriatric patients
Macrolide drug interactions
-Competes for liver metabolism with many different drugs because it is highly protein bound
-Ex) carbamazepine, cyclosporine, digoxin, theophylline and warfarin
Macrolide nursing implications
-Severe allergies? Therapeutic response?
-Monitor skin & bowel function
-Re-evaluate lab work- May see elevated liver enzymes
B-lactam antibiotics are characterized by the..
Chemical structure that involves a β-lactam ring
B-lactam has a …
Time dependant killing action and relies on time vs. a specific [ ] of antibiotic
Types of B-lactam antibiotics
Cephalosporins, carbapenems, monobactams and penicillins
Penicillin general information
-Derived from mould fungus and is often found on bread or fruit
-The broad-spectrum penicillins (amoxicillin, ampicillin) were introduced in WWII and have remained well-trusted antibiotics to date
Penicillin is a…
Broad spectrum antibacterial activity against gram-positive and limited activity with gram-negative bacteria
Penicillin has a..
Narrow spectrum
Penicillin indications
-Streptococcus, enterococcus and staphylococcus
-Ear infections, pneumonia, UTIs, STIs and prophylaxis prior to surgery
Penicillin MOA
-Bactericidal
-Inhibit bacteria cell wall synthesis by infiltrating the cell which makes it unstable and breaks it down
Penicillin adverse effects
-GI upset is most common
-Allergic reactions include urticaria, pruritus and angioedema
-Unpredictable drug reactions include maculopapular eruptions, eosinophilia, Stevens-Johnson syndrome and exfoliative dermatitis
Penicillin drug interactions
-Additional antibiotics have additive/inhibitory effects
-NSAIDS compete for protein binding which could result in more active & free penicillin
-Oral contraceptives decrease its effectiveness
-Potassium supplements may increase effects of hyperkalemia
-Warfarin
Penicillin nursing implications
-Monitor skin & bowel function
-Re-evaluate lab work
-Evaluate therapeutic response
Cephalosporin general information
-Derived from a fungus but is synthetically altered to produce an antibiotic that is very similar to penicillins
-4-5 different generations
Cephalosporins have a…
Broad spectrum antibacterial activity against gram-positive and limited activity with gram-negative bacteria
Each new generation of cephalosporin can…
Focus on different bacterial strains
Cephalosporin indications
UTIs & respiratory infections
Cephalosporin MOA
-Bactericidal action
-Inhibits bacteria cell wall synthesis by infiltrating the cell and binding to proteins making it unstable and breaking it down
Cephalosporin adverse effects, contraindications/drug interactions and nursing implications are
Similar to penicillin antibiotics (go back)
Monobactam general information
Not marketed in Canada
Monobactam is…
Primarily active against gram-negative bacteria
Monobactam indications
Used for moderately severe systemic infections and UTI’s
Monobactam MOA
-Bactericidal action
-Inhibits bacteria cell wall synthesis by infiltrating the cell and binding to proteins making it unstable and breaking it down
Carbapenem general information
-Broadest antibacterial action of any antibiotics
-Potent & heavy hitting antibiotics
-Immune to the effects of B-lactamase
Carbapenem is often…
Reserved for complicated body cavity and connective tissue infections in acutely ill hospitalized patients
Carbapenam is a…
Broad spectrum antibacterial activity against gram-positive & gram-negative bacteria
Carbapenem indications
-Bone, joint, skin, and soft tissue infections; bacterial endocarditis, intra-abdominal infections, pneumonias, UTI’s, pelvic infections and bacterial septicemia
Meropenem is the…
Only drug effective for bacterial meningitis
Carbapenem MOA
-Bactericidal action
-Inhibits bacteria cell wall synthesis by infiltrating the cell and binding to proteins making it unstable and breaking it down
Carbapenem adverse effects
-Seizures and confusion**
-GI upset & rash
Carbapenem drug interactions
Cyclosporin, ganciclovir & probenecid may cause CNS adverse effects (seizures/confusion)
Carbapenem contraindications
Pregnancy, hx of renal disease, geriatrics and seizures disorders
Carbapenem nursing implications
Monitor skin, bowel, therapeutic response and CNS function
-Re-evaluate lab work
Tetracycline general information
Most commonly given PO in a tab/cap
Tetracycline indications
-Wide range antibiotic (Both Gram +/-)
-Acne, chlamydia, pneumonia’s, UTI’s and skin infections
Tetracycline MOA
-Bacteriostatic
-Protein synthesis inhibitor
Tetracycline adverse effects
-Discolouration of teeth in fetuses and children and disrupted fetal skeletal development if taken during pregnancy
-Photosensitivity (sunburn), diarrhea, yeast Infection and aUrine colour
Tetracycline contraindications
-Pregnancy/breastfeeding
-Children under 8 years old
-When taken with calcium & iron
Tetracycline drug interactions
Anticoagulants, bactericidal antibiotics & oral contraceptives
Tetracycline nursing implications
-Take 1 hour before or 2 hours after meals/snack
-Take at least 4 hours after antacid
-Do not take with food especially dairy products
-Administer around the clock
Aminoglycoside general information
-Very Potent
-Not given orally d/t poor absorption
-Usually given with Beta-Lactams/ Vancomycin to provide a synergistic effect
Aminoglycoside fights…
Mostly gram negative & some gram positive
Aminoglycoside indications
Serious infections, GI/GU infections, endocarditis and respiratory tract infections
Aminoglycoside MOA
Bactericidal, protein synthesis inhibitor and disrupts the cell membrane
Aminoglycoside adverse effects
Ototoxicity, nephrotoxicity and drug toxicity
Aminoglycoside contraindications
Renal impairment and pregant or breastfeeding women
Aminoglycoside drug interactions
Loop diuretics and oral anticoagulants
Aminoglycoside implications
-Renal Assessment
-Neurological assessment; dizziness, vertigo, tinnitus, roaring in ears and hearing loss
-Therapeutic drug monitoring
Fluoroquinolones general information
Very potent
Fluoroquinolones are for…
Mostly gram negative and some gram positive
Fluoroquinolone indications
Complicated UTI’s and respiratory tract infections
-Skin, GI, bone, and joint infections
Fluoroquinolone MOA
-Bactericidal
-Alter DNA of bacteria
Fluoroquinolone adverse effects
Central nervous, skin, GI, elevated ALT/AST, and prolonged QT interval
Fluoroquinolone contraindications
Cardiac dysrhythmias
Fluoroquinolone drug interactions
Antacids, anticoagulants, calcium/magnesium, bronchodilators and iron/zinc preparations
Fluoroquinolone nursing implications
-May be taken with meals (except dairy alone)
-Reduce caffeine if excessive cardiac or CNS stimulation occurs
-Maintain hydration/urine output
Clindamycin general information
Derived from old antibiotic lincomycin
Clindamycin is for…
Both gram + & -
Clindamycin indications
Chronic bone infections, UTI’s, intra-abdominal infections, anthrax, endocaditis and malaria
Clindamycin MOA
-Can be both bactericidal/static based on the dose
-Protein synthesis inhibitor
Clindamycin adverse effects
GI upset, joint pain, thrush and yeast infection
Clindamycin contraindications/drug interactions
-Ulcerative colitis
-Neuromuscular drugs
Clindamycin nursing implication
-May be taken with food
-Bowel assessment
Metronidazole general information
-Flagyl
-Class: Nitroimidazole
Metronidazole indications
Intra-abdominal and gynaecological infections
Metronidazole MOA
-Bactericidal
-Alter DNA of bacteria
Metronidazole adverse effects
GI, nasal congestion, neutropenia and thrombocytopenia
Metronidazole contraindications
Breastfeeding mother
Metronidazole drug interactions
Antidepressants, ETOH, Li+, benzodiazepine, cyclosporin and CCBs
Metronidazole nursing implications
-Keep hydrated
-Take on full stomach to avoid digestive upset
Vancomycin general information
Treatment of choice for MRSA
Vancomycin indications
MRSA, C. diff, bone and bloodstream infections
Vancomycin MOA
-Bactericidal
-Destroys bacteria cell wall causing cell death
Vancomycin adverse effects
Ototoxicity, nephrotoxicity, ‘Red Man Syndrome’ and neutropenia
Vancomycin contraindications
-Hearing condition and kidney dysfunction
-Take caution with neonates/older adults
Vancomycin drug interactions
Neuromuscular blockers
Vancomycin nursing implications
Therapeutic drug dose, stay hydrated & monitor U/O
Definition of inflammation
A localized protective response stimulated by injury to tissues, which serves to destroy, dilute, or wall off both the injurious agent and the injured tissue
Anti-inflammatory medication MOA
Blocks the arachidonic acid (repair®row) pathway
Anti-inflammatory medications
Nonsteroidal & corticosteroids
Salicylates
Aspirin & diflunisal
Acetic acid derivatives
-Diclofenac Na+, indomethacin suindac, etodolac, ketorolac and mefenamic acid
-Things that end in “ic” OR “ac” (puts the “ace” in acetic acid)
COX-2 Inhibitors
Celecoxib
Enolic acid derivatives
Nabumentone, meloxicam and piroxicam
Propionic acid derivatives
-Flurbiprofen, ibuprofen, ketoprofen, naproxen and oxaprozin tioprofenic
-Things that have “pro” in them
NSAID
Large group of medications accounting for over 4% of all prescriptions in Canada
4 primary properties
Analgesics, anti-inflammatory, anti-arthritic and antipyretic activities
NSAIDS are used for…
Mild-moderate headaches, myalgia, neuralgia and arthraigia, alleviation of post operative pain and inhibition of platelet aggregation
Arthritic disorders such as
Ankylosing spondylitis, and tx of gout & hyperuricemia
Recommended NSAID for ankylosing spondylitis
Indomethacin, naproxen and flurbiprofen
Recomended NSAID diabetic neuropathy
Sulindac
Recommended NSAID for dysmenorrhea
Fenamates, naproxen and ibuprofen
Recommended NSAID for gout
Indomethacin, naproxen and sulindac
Recommended NSAID for headaches
Aspirin, ibuprofen and naproxen
Recommended NSAID for hepatotoxicity
Naproxen, ibuprofen, piroxicam and fenamates
Recommended NSAID for a hx of aspirin or NSAID allergy
Avoid NSAIDs if possible; if deemed necessary, consider a nonacetylated salicylate
Recommended NSAID for HTN
Sulindac, nonacetylated salicylate, ibuprofen and etodolac
Recommended NSAID for OA
Diclofenac, oxaprozin and indomethacin
Recommended NSAID for pt at risk for GI toxicity
All COX-2 inhibitors
Recommended NSAID for pt at risk for nephrotoxicity
Sulindac, nonacetylated salicylate, nabumetone, etodolac, diclofenac and oxaprozin
Recommended NSAID for warfarin therapy
Sulindac, naproxen, ibuprofen and oxaprozin
Contraindications of NSAID use
-Conditions that place the pt at risk for bleeding; epistaxis, vitamin K deficiency and PUD
-Not recommended for breastfeeding mothers and take caution in pregnant women
Anti-inlammatory adverse effects on CV
Moderate to severe noncardiogenic pulmonary edema
Anti-inflammatory adverse effects on GI
Dyspepsia, heartburn, epigastric distress, N/V, anorexia, abd pain, GIB, mucosal lesions
Anti-inflammatory hematological adverse effects
aHemostasis through effects on platelet function
Anti-inflammatory hepatic adverse effects
Acute reversible hepatotoxicity
Anti-inflammatory adverse effects on the renal system
Reduction in CrCl and tubular necrosis w kidney failure
Other anti-inflammatory adverse effects
Skin eruption, sensitivity reactions, tinnitus and hearing loss
Anti-inflammatory interaction with ETOH
Additive effect that may cause a GIB
Anti-inflammatory interaction with anticoagulants
Platelet inhibition and hypoprothrombinemia which increases bleeding tendencies
Anti-inflammatory interaction with antihyperglycemic drugs
Increased antihyperglycemic response to sulfoneureas which reduces BG
Antiinflammatory interaction with SA and other salicylates with NSAIDs
Reduces NSAID absorption and has additive GI toxicities which increase GI toxicity with therapeutic advantage
Anti-inflammatory interaction with corticosteroids and other ulcerogenic drugs
Additive toxicities and increased ulcerogenic effect
Anti-inflammatory interaction with cyclosporines
Inhibits kidney prostaglandin synthesis and increases the nephrotoxic effects of cyclosporine
Anti-inflammatory interactions with hypotensive drugs & diuretics
Inhibits prostaglandin synthesis and reduces hypotensive/diuretic effects
Anti-inflammatory interaction with phenytoin
Inhibit phenytoin metabolism and increases its serum levels
Anti-inflammatory interactions with protein-bound drugs
Compete for binding and more pronounced drug actions
Anti-inflammatory interactions with uricosurics
Antagonistic effect that reduces uric acid secretion
NSAID overdose S&S
Lethargy, drowsiness, confusion, disorientation, paraesthesia, numbness, aggression & seizures
GI toxicities + anti-inflammatories
N/V & GIB
Adverse effects of anti-inflammatories
GI toxicity, headache, dizziness, cerebral edema, cardiac arrest & death
CVD risk + NSAIDs
-May increase the risk of thrombosis
-NSAIDs are contraindicated in the perioerative CABG setting
GI risk + NSAIDs
Elderly pt are at greater risk
Anti-inflammatory meds + lab values to monitor
-Hemoglobin, hematocrit, hyperkalemia, hyponatremia, AST & ALT (hepatotoxicity is rare)
Specific conditions r/t NSAIDs
Gout & Reye’s syndrome
Gout
-Elevated uric acid crystals in tissues/joints
Allopurinol + gout
Prevents uric acid production
Colchicine + gout
Reduces the inflammatory response to deposits of uric crystals; used in acute tx
Reye’s syndrome
Aspirin is contraindicated in children with viral illnesses and may result in encephalopathy or liver damage
S&S of Reye’s syndrome
aLOC, coma, flaccid paralysis, loss of deep tendon reflexes, seizures & vomiting
Corticosteroids
Mineralocorticoids & glucocorticoids
Mineralocorticoids
Aldosterone; regulates Na+, influences K+ & causes metabolic alkalosis
Glucocorticoids
-Also have anti-inflammatory properties
-Systemic or topical glucocorticoids are available in short, intermediate and long acting forms
All naturally occuring corticosteroids in the body are…
Available in exogenous form
Systemic glucocorticoids
-Prednisone; oral and intermediate acting
-Solu-cortef: Hydrocortison Na+, IV form
Corticosteroids MOA
r/t the synthesis of specific proteins & indirectly modify enzyme activity
Mineralocorticoid aldosterone
Effect fluid & electrolyte balance on the distal kidney tubule
Glucocorticoid hydrocortisone
Inhibits inflammatory & immune response
Corticosteroids control the…
Inflammatory response by stabilizing cell membranes
Corticosteroid indications (1)
Allergies, bacterial meningitis, cancers, cerebral edema, chronic respiratory illness, skin disease and endocrine disorders
Corticosteroid indications (2)
-GI, rheumatic & hematological disorders
-Nonrheumatic inflammation, nephrotic syndrome, organ transplant, leukemias and lymphomas
Corticosteroid contraindications
Cataracts, glaucoma, PUD, mental health concerns and DM
Corticosteroid CV adverse effects
-HF, cardiac edema and HTN—all caused by electrolyte imbalances (hyperkalemia, hyponatremia)
-Impaired glucose tolerance, dysrhythmias, bradycardia, pulmonary edema, syncope and vasculitis
Corticosteroid CNS adverse effects
Convulsions, vertigo, mood swings, nervousness, aggressive behaviours, psychotic symptoms, neuritis, peripheral neuropathy, paresthesia, arachnoiditis, meningitis and insomnia
Corticosteroid endocrine system adverse effects
Growth suppression, Cushing’s syndrome, menstrual irregularities, carbohydrate intolerance, hyperglycemia, hypothalamic–pituitary–adrenal axis suppression, hirsutism, hypertrichosis and glycosuria
Corticosteroid GI adverse effects
Peptic ulcers, pancreatitis, ulcerative esophagitis and abdominal distension
Corticosteroid skin adverse effects
Fragile, dry, hyperpigmented, petechiae, ecchymosis, facial erythema, poor wound healing, urticaria, acne and stria
Corticosteroid MSK adverse effects
Myopathy, atrophy, osteoporosis, osteonecrosis of femoral & humeral heads, pathological fracture and malaise
Corticosteroid ocular adverse effects
IIOP, glaucoma & cataracts
Corticosteroid “other” adverse effects
Weight gain, leukocytosis, opportunistic infections, hypokalemia and alkalosis
Systemic corticosteroid interactions with non-potassium sparing diuretics
Hypocalcemia & hypokalemia
Systemic corticosteroid interactions with aspirin & other NSAIDS
GI effects and gastric ulcer development
Systemic corticosteroid interactions with cholinesterase drugs
Weakness with myasthenia gravis
Systemic corticosteroid interactions with immunizing biologics
Inhibit immune response
Systemic corticosteroid interactions with antidiabetic drugs
Elevated blood glucose
Glucocorticoid pt teachings
-Adrenal crisis may occur if glucocorticoid is abruptly stopped
-Glucocorticoid inhalers require mouth rinse to prevent fungal infections
-Surgeon must be aware of pt taking glucocorticoid. Pt may be switched to rapid acting medication. Dose may need to be increased in the immediate post-op period
Routes of corticosteroids
PO, IM, IV, intranassally & inhaled
Corticosteroids cause…
Endogenous glucocorticoid levels to decrease. For levels to resume, exogenous levels must be decreased gradually so that hormone output responds to the negative feedback system. Abrupt withdrawal may lead to Addison’s disease
Do not give corticosteroids with…
Aspirin or other NSAIDS to minimize the risk of gastric irritation and possible gastric bleeding from compounding ulcerogenic effects
Oral corticosteroids should be…
Given with milk or food to help minimize GI upset
Monitor blank with corticosteroids
Therapeutic response and adverse effects including Cushing’s syndrome
