Exam 1 Antibiotics and Respiratory Flashcards
1
Q
Goals and General Rules for Antibiotics
A
inhibit organisms at concentrations that are tolerated by the host
seriously ill/immunocompromised- bactericidal
narrow spectrum before broad spectrum or combination therapy to preserve normal flora
2
Q
Why does anesthesia care about antimicrobals
A
timely administration
reimbursement for quality care
potential for adverse reactions
cross reactions with other medications we administer
3
Q
Potential for adverse reactions with abx
A
hypersensitivity reaction (dose dependent)
direct organ toxicity (dose dependent)
potential for superinfections
identify patient at risk for complications
4
Q
SSI are the ____ most common healthcare associated infection
A
second
5
Q
SSI develop in ____ of 30 million surgical patients
A
2-5%
6
Q
Represent approx. _____ of all hospital acquired infections annually in the US and cost ___ dollar/year
A
14-16%
1 billion
7
Q
SSIs account for __ of surgical mortality and lead to
A
3%
increased readmissions
increased LOS
increased hospital costs
8
Q
SSI defined
A
as an infection related to a operative procedure that occurs at or near the surgical incision within 30 days of the procedure
9
Q
Additional details of SSI
A
purulent exudate draining from a surgical site
+ culture obtained form a surgical site that was closed initally
surgeon’s diagnosis of infection
surgical site that requires re-opening to at least one of the following signs or symptoms: tenderness, swelling , reddness, heat
10
Q
Surgical Risks for Infection
A
procedure type
skill of surgeon
use of foreign material or implantable device
degree of tissue trauma
11
Q
Patient Risks for SSI
A
diabetes smoking obesity malnutrition systemic steroid use immunosuppressive therapy intraop hypothermia trauma prosthetic heart valves
12
Q
Anesthesia providers use of antibiotics can decrease infection with
A
timely and appropriate use of antibiotics
maintenance of normothermia
proper syringe/med administration practices
13
Q
SSI Prevention Antibiotic Timing
A
antibiotic prophylaxis 1 hour before incision
30-60 min before incision is the ideal window for drug administration
14
Q
hypothermia is associated with
A
increased Blood loss, increased transfusions requirement prolonged PACU stay impaired immue dysfunction compromised neutrophil function leads to vasoconstriction tissue hypoxia and increased SSI
15
Q
SBE Prophylaxis
A
amoxicillin 2gm PO
IV ampicillin 2 gm IV
Pencillin Allergy: Ceftriaxone 1gm IV
cefazolin 1gm IV (not in patients with hypersensitivity to PCN)
16
Q
ceftazolin, cefuroxime or vancomycin
if B lactam allergy, vancomycin or clindamycin
A
cardiothoracic and vascular surgery
17
Q
Cefetan, cefazolin, cefoxitin, cefuroxime, ampillicin/bactrim
B lactam allergy: clinda + gent or cipro or met +gent or clindamycin monotherapy
A
hysterectomy
18
Q
Cefazolin or cefuroxime
B lactam- vancomycin or clindamycin
A
hip or knee anthroplasty
19
Q
Cefotetan, cefoxitin + met or amp/sulbactam
A
Colon
20
Q
Bactericidal antibiotics
A
kill the susceptible bacteria
21
Q
bacteriostatic antibiotics
A
reversibly inhibit the growth of bacteria
duration of therapy must be sufficient to allow cellular and humoral defense mechanism to eradicate the bacteria
22
Q
Bactericidal Antibiotics
A
pencillins & cephalosporins isoniazid metronidazole polymyxins rifampin vancomycin aminoglycosides quinolones
23
Q
Bacteriostatic Antibiotics
A
chloramphenicol clindamycin macroslides sulfonamides tetracyclines trimepthoprim
24
Q
Structure and Organism of Pencillin
A
basic structure of dicyclic nucleus with thiazolidine ring connected to B-lactam ring Bactericidal pneumococcal meningococcal streptococcal actinomycosis
25
MOA of Pencillin
interacts with synthesis of peptidoglycan which is essential to component of cell walls of susceptible bacteria
26
Excretion of Pencillin
renal excreted rapidly, plasma concentration decrease 50% in first hour
10% glomerular filtration/90% renal tubular secretion
anuria increases elimination half time by 1/2fold
27
DOA of Pencillin
administration of probenecid will reduce renal excretion and prolong action
28
Adverse Reactions of Penicillin
```
hypersensitivity
most allergenic of antimicrobals
rash/fever
hemolytic anemia
maculopapular rash
```
29
What drugs is common with cross senisitivity with pencillin?
3% B-lactam ring
30
Penicillin Uses
```
otitis media
meningitis
sore throat
pneumonia & respiratory infections
septicemia
gonorrhea/UTIs
```
31
Organisms treated by Second Gen Penicillin
```
pneumoncoccal
meningococcal
streptococcal
actinomycosis
wider range of activity (gram - H. influenza and Ecoli
```
32
Second Generation Penicillins Examples
amoxicillin
| ampicillin
33
Cefazolin
bactericidal antimicrobals that inhibtit bacterial cell wall synthesis and have low toxicity
broad spectrum activity
low allergy incidence (1-10%)
anaphylaxis is 0.02% (due to B lactam ring)
cross sensitivity with other Cephalosporins
RENALLY EXCRETED
34
Generations of Cephalosporins
Start with stronger GRam + coverage then increase Gram - coverage as increase class
35
Macrolides Examples
Erythromycin and Azithromycin
36
Macrolides
compounds characterized by a macrolytic lactone ring containing 14-16 atoms with a deoxy sugar attached
Erythromycin protype
37
Macrolides are effective against
gram + bacilli, pneumococci, streptococci, staphylococci, mycoplasma and chlamydia
38
Erythromycin
bacteriostatic or bactericidal depending on dose
39
Metabolism of Erythromycin
CYP 450 system and thus increase concentration of theophylline, warfin, cyclosporin, methylpredinisone and digoxin
40
Excretion of Erythromycin
bile
41
Do you alter erythromycin dose for renal patients?
no
42
Side effects of Erythromycin
GI intolerance (due to increase peristalsitis)
severe NV after IV infusion
gastric emptying
cholestastic hepatitis
QT effects- prolongs cardiac repolarization
reports of torsades de pointes
thrombophelitis
43
Clindamycin
linomycins
bacteriostatic
similar to erythromycin in antimicrobal activity
more active with anerobes
pseudomembranous colitis-> severe diarrhea should indicate discontinuation of therapy
44
Dosing of Clindamycin
only 10% administered dose is excreted unchanged in urine, rest is inactive
45
Decrease Clindamycin dose with
severe liver disease
46
Clinda is common for
female GU surgeries
47
Side Effects of Clindamycin
Rapid IV dose: Hypotension
skin rash
prolonged pre and post junctional effects at NMJ in the absence of ND NMB
not antagonized with anticholinesterases or calcium
concurrent administration with NDMR can produce long lasting profound NM
48
Vancomycin- Glycopeptide Derivative
Bacteriocidal impairs cell wall synthesis
effective for gram + bacteria (severe staph infections)-- streptococcal, enterococcal, endocarditis
DOC for Methicillin resistant staph aureus (MRSA)
49
Vanco is administered with for
aminoglychoside for endocarditis
50
Vancomycin is excreted
via kidney 90% unchanged in urine
51
Elimination 1/2 time of Vanco
6 hours but can be prolonged in renal failure patients
52
S/E of vancomycin
rapid infusion- red man's syndrome
| ototoxicity/nephrotoxicity/ return of NMB
53
Dose of Vancomycin
10-15mg/kg over 60 mins
| 1 gm mixed in 250ml
54
Vanco is used for
cardiac/orthopedic procedures using prosthetic devices and CSF, shunt related infections
55
Indications for Vancomycin
MRSA, endocarditis due to strep. v or enterococci
| patients allergic to B lactams
56
pharmacokinetics of vancomycin
poor oral absorption
IV administration
renal excretion by glomerular filtration (80-90%) in 24hr
slow CSF penetration unless there is meningeal inflammation
57
Side effects of Vancomycin
```
phlebosclerotic (irritating to tissue)
nephrotoxicity rare unless with other drugs
ototoxicity > 300mcg/ml
hypersensitivity
hypotension & red mans
```
58
Red Man's syndrome
flushing due to histamine release
59
Administer diphenhydramine and cimetidine 1 hour before induction to limit histamine related effects
1mg/kg
| 4mg/kg
60
Aminoglycoside Drug Examples
Streptomycin &Kanamycin
Gentamycin
Amikacin
Neomycin
61
Streptomycin & Kanamycin
limited uses
| frequent occurance of vestibular damage
62
Gentamicin
broader spectrum
| toxic level >9mcg/ml
63
Amikacin
derivative of kanamycin
| treatment of infections caused by gentamicin or tobramycin resistant gram negative bacilli
64
Neomycin
treatment for skin, eye and mucous membrane infections
adjunct therapy to hepatic coma
administered to decrease bacteria in intestine before GI surgery
most nephrotoxic
65
Aminoglycosides
bactericidal (effective for gram negative and gram +)
generally prescribed combination therapy with beta lactam antibiotic for Gram -
Mycobaterium Tuberculosis
66
Excretion for Aminoglycosides
extensive renal excretion through glomerular filtration
67
Elimination time of Aminoglycosides
2-3 hours that can be increased with renal failure (20-40x)
68
Side effects of Aminoglycosides
```
limited by toxicity
ototoxicity
nephrotoxicity
skeletal muscle weakness
potentiation of NDMR blockade
```
69
Muscle weakness of Aminoglycosides
inhibit the pre-junctional release of Ach and decreases post-synaptic sensitivity to the NT
most impt with neuromuscular path patients (MG)
70
Potentiation of NMR with aminoglycosides with Depolarizing or ND?
Non-depolarizing drugs
| result can be reversed with calcium gluconate or neo but it will not be sustained
71
Examples of Fluroquinolones
ciprofloxacin
| moxifloxacin
72
Ciprofloxacin
treats respiratory infections, tuberculosis and anthrax
73
Moxifloxacin
```
suitable for long acting treatment of acute sinusitis, bronchitis, complicated Ab wounds
QT prolongation
peripheral neuropathy
psychosis
SJS
```
74
Fluroquinolones
broad spectrum, bactericidals
effective for gram - bacilli and myobactrium
useful for treatment of complicated GI GU infections
75
Cipro useful in treatment of
variety of systemic infections including bone, soft tissues, and resp tract
76
Pharmacokinetics of Fluroquinolones
Rapid GI absorption and penetrates fluids and tissues well
renally excreted, through glomerular filtration and renal tubular secretion
Renal Dosing Required
Elimination 1/2 time: 3-8 hours
can inhibit CYP 450 enzymes
77
Side effects of Fluoroquinolones
```
Mild GI disturbances
N/V
CNS dizziness, insomnia,
Tendon or Achilles rupture
muscle weakness in patients in MG
```
78
Sulfonamides, Sulfamethoxazole and trimethoprim
Bacteriostatic
antimicrobial activity due to the ability of these drugs to prevent normal use of PABA by bacteria to synthesize FA
inhibits microbial synthesis of folate production
portion of drug is acetylated in the liver and other is renally excreted
Renal Dosing required
79
Clinical Uses of Sulfonamides, Sulfamethoxazole and trimethoprim
urinary tract infections
inflammatory bowel disease
burns
80
Side Effects of Sulfonamides, Sulfamethoxazole and trimethoprim
```
skin rash to anaphylaxis
photosensitivity
allergic nephritis
drug fever
hepatotoxicity
acute hemolytic anemia
thrombocytopenia
increase effect of pro anticoagulant
```
81
Metronidazole
Bactericidal
| anaerobic gram negative bacilli clostridum
82
What drug is useful for: CNS infections, abdominal and pelvic sepsis, pseudomembranous colitis (CDiff), and endocarditis?
metronidazole
| recommended for colorectal surgery
83
Pharmacokinetics of Metronidazole
well absorbed orally and widely distributed in tissue including CNS
PO IV
84
Side effects of Metronidazole
dry mouth
metallic taste
nausea
avoid alcohol
85
Antimycobacterial Agents (1st line)
```
isoniazid
rifampin
ethambutal
pyrazinamide
used in combination therapy (3 4 agents) for 2 months followed by minimum of 4 months of therapy with 2 agents
```
86
Isoniazid
bacteriostatic
bactericidal if bacteria are dividing
hepato-renal toxicity
decrease platelets and anemia
87
Rifampin
bacteriocidal
hepatic enzyme induction
hepat-renal toxicity, thrombocytopenia, anemia
very potent, inducer of hepatic enzyme, increase NDMR , re-dose alot
88
Ethambutol
bacteriostatic
| optic neuritis
89
Pyrazinamide
bacteriostatic
| liver toxicity
90
Side Effects of Amphotericin B
```
fever, chills, dyspnea, hypotension, can occur during infusion
impaired hepatic function
hypokalemia
allergic reactions
seizure
anemia
thrombocytopenia
```
91
Amphotericin B
given for yeast and fungi
poor PO absorption
slow renal excretion
92
Renal Function and Amphotercin B
renal function is impaired in 80% of patients treated wiith this drug
most recover after drug is stopped but some result in permenant decrease in GFR
watch Cr levels
93
Acyclovir
used to treat herpes
may cause renal damage if infused rapidly
thrombophlebitis
patients may complain of headache during infusion
94
Interferons
designate glycoproteins produced in response to viral infections
bind to receptors on host cell membranes and induce the production of enzymes that inhibit viral replication (degradation of viral mRNA)
enhance tumoricidal activities of macrophages
treatment for chronic hepatitis B and C
nasal spray
95
Side effects of Antivirals
```
flu like symptoms
hematologic toxicity
depression, irritability
decreased mental concentration
development of autoimmune conditions
rashes alopecia
changes in CV thyroid and hepatic function
```
96
Triple Therapy
Drugs chosen from 6 classes
97
Importance of CRNA to note with antiretrovirals
existence of adverse effects (liver toxicity, peripheral neuropathy, nephro-toxicity, neuromuscular weakness)
interactions with other medications) proton pump inhibitors, cimetidine, NMDR, benzo)
98
Six Classes of antiretrovirals:
```
nucleoside/non nucleotide reverse transcriptionast inhibitors (NRTI & NNRTIs) delaviridine
Protease Inhibitors- ritonavir
fusion inhibitors- enfuvirtide
CCR5 receptors antagonist
integrase inhibitors- lamivudine
```
99
Take Aways of Antimicrobals
appropriate stewardship of antimicrobal use
infection prevention- SCIP
types of antibiotics cidal vs static
antibiotic classes and ATB: b lactams, linomycins, vancomycin, aminoglycosides
muscular weakness
anti-virals side effects
100
S/E of antiretrovirals
```
pancreatitis
hepatotoxicity
lactic acid
fat re-distribution
increase plasma concentration of Ca blockers, NMB, and
```
