Unit 5 Flashcards
Indications: Safe alternative to penicillins Empiric treatment of CAP Whooping cough Legionnaire’s disease H. influenza Mycoplasma pneumonia Chlamydia
Macrolides
Antibiotic contraindicated in pregnancy
Tetracyclines
AEs:
Red-man syndrome due to histamine release
• Causes hypotension, flushing, red rash on upper body during infusion
• Slow infusion down to treat this
Renal failure- monitor drug levels
Ototoxicity with prolonged use
Immune-mediated thrombocytopenia- low platelets/spontaneous bleeding
Vancomycin
MOA:
Narrow spectrum
Reserved for severe infections from gram + organisms
Inhibits cell wall synthesis and RNA synthesis
Vancomycin
Reversible inhibition of COX 1 and 2
o do not protect against MI and stroke
o Can cause GIB, GI upset, and renal impairment
Non-ASA NSAIDs (ibuprofen, naproxen)
MOA:
Inhibits xanthine oxidase, which is an enzyme required for uric acid formation
Allopurinol
Indications:
First-line treatment to abort migraines
Relieves migraine symptoms
Can also be used for cluster HA
Serotonin 1B/1D Receptor Agonists (triptans)
Drug interactions: warfarin, theophylline, ampicillin
Allopurinol
MOA- Can be bacteriostatic or bacteriocidal depending on the type of drug and dosage
Interfere with bacterial cell wall synthesis
Penicillin
Contraindications:
Don’t use with ergot alkaloids- will result in excessive vasoconstriction
MAOIs- suppresses hepatic degradation of sumatriptan
SSRIs/SNRIs- excessive activation of serotonin, can result in serotonin syndrome
Serotonin 1B/1D Receptor Agonists (triptans)
Migraine med that can cause physical dependence
Ergot Alkaloids
MOA:
Bacteriostatic or bacteriocidal depending on dose
Binds to 50S ribosomal subunit to block addition of new aminoacids to the growing peptide chain
Macrolides
Contraindications:
Hematologic disorders
Drug interactions- statins, drugs that increase colchicine levels
Pregnancy category C
Colchicine
o COX 1 and 2 inhibition
o Suppress pain and inflammation but pose a risk of gastric ulceration, bleeding and renal impairment
First Generation NSAIDs (ASA, ibuprofen, naproxen)
MOA:
Causes selective activation of 5-HT (serotonin) 1B/1D receptors, resulting in vasoconstriction and suppresses release of CGRT which decreases release of inflammatory neuropeptides and decreases inflammation
Serotonin 1B/1D Receptor Agonists (triptans)
Which patient should not receive an opiate agonist-antagonist?
A patient with physical dependence- this may precipitate withdrawal
Biologic DMARD- causes destruction of B lymphocytes
Rituximab
Nursing Implications:
Cross into BM, fetal tissues, CNS
Pregnancy category D
ASA
E. coli, klebsiella, and pseudomonas
Gram -
Activation results in analgesia, respiratory depression, euphoria, and sedation
Related to physical dependence
Mu receptors
AEs: N/V (stimulates chemo trigger zone) Myalgias Weakness in legs Numbness/tingling in fingers/toes Angina-like pain Tachycardia/bradycardia
Ergot Alkaloids
COX 1 or 2 inhibitors? Causes gastric erosion and ulceration o Increases bleeding tendencies o Causes renal impairment o ***but can protect against MI and stroke*** due to reduced platelet aggregation
1
AEs:
Injection site reactions- itching, erythema, swelling, pain
Serious infections- body cant fight infection (TB special concern)
Severe allergic reactions
HF- new and existing
CA
Hematologic disorders
Liver injury
CNS demyelinating disorders- MS, myelitis, optic neuritis
Etanercept
AEs: Minimal toxicity Allergic reaction- can be mild to anaphylactic (cross sensitivity with cephalosporins if allergy is > mild) Neurotoxicity Nephropathy Hematologic effects Immunologic effects GI effects (n/v/d)
Penicillins
What class of abx? ciprofloxacin
fluoroquinolone-2nd gen
o Pain relief and fever reduction only
o No effects on inflammation or antirheumatic actions (does not suppresses platelet aggregation, cause gastric ulceration, reduce RBF or cause renal impairment)
o Minimal effects on COX
Acetaminophen
4 processes for antibiotic selection
Allergy hx, age, pregnancy, site of infection
Biologic DMARD- inhibits activation of T lymphocytes
Abatacept
Nursing Implications:
Monitor liver and kidney levels
Monitor CBC
Methotrexate
AEs:
Gastric ulceration, bleeding, renal impairment
Heart burn, nausea
Salicylism- when ASA levels are above therapeutic threshold (tinnitus, sweating, HA, dizziness, acid-base imbalance)
Reye’s syndrome in children- encephalopathy and fatty liver degeneration (happens in conjunction with influenza or chickenpox)
Hypersensitivity reaction
ED
ASA
When are cephalosporins used for second-line therapy?
Acute bronchitis
Acute otitis media
Pharyngitis
MOA: Acts on renal tubules to inhibit reabsorption of uric acid
Probenecid
Indications:
Second-line therapy for stopping ongoing migraine for people who do not respond to triptans
Ergot Alkaloids
Can cause fetal death and congenital abnormalities
May reduce life expectancy in patients taking this drug….from increased risk of CV disease, infection and certain cancers
Give with folic acid to reduce GI upset and hepatic toxicity
Methotrexate
What class of abx? levofloxacin
fluoroquinolone- 3rd gen
o AEs- dyspepsia, abdominal pain, renal impairment, sulfa allergy (cross sensitivity)
o Drug interactions- warfarin
Celebrex
MOA:
Inhibits leukocyte infiltration by disrupting microtubules, which are structures required for cellular motility
*Toxic to any tissue that has a large percentage of proliferating cells
Colchicine
What class of abx? erythromycin
Macrolides
Streptococcus, Staphylococcus, and Enterobacter
Gram +
MOA:
binds with TNF tightly and prevents TNF from interacting with its natural receptors on cells
Etanercept
Adverse Effects:
Chest symptoms- heavy arms/chest pressure (maybe from pulmonary vasoconstriction, esophageal spasm)
Coronary vasospasm- angina and EKG changes
Teratogenesis- category C
Others- vertigo, fatigue, tingling sensations
Serotonin 1B/1D Receptor Agonists (triptans)
Indications:
Used as alternatives to other antibiotics
Infections caused by E. coli
Infections of bones, joints, GU/GI and respiratory PNA
Treatment of anthrax exposure
1st gen- uncomplicated UTIs (nadilixic acid)- rarely used anymore
2nd gen- increased gram – and systemic activity- norfloxacin and ciprofloxacin
3rd gen- levofloxacin- gram + for pneumonias (first-line for CAP who have co-morbidities)
4th gen- moxifloxacin and Gemifloxacin- resp infections, effective against anaerobic bacteria
Fluoroquinolones
MOA:
Bacteriostatic and bacteriocidal
Inhibits cell wall synthesis
Cephalosporins
Contraindications:
Patients with severe penicillin allergy (cross-sensitivity)
Cephalosporins
What class of abx? cefazolin (Ancef)
cephalosporin- 1st gen
Contraindications:
Do not use in children under 18 (only indications for under 18 is treatment for complicated UTIs and pyelonephritis)
Fluoroquinolones
Commonly associated with respiratory tract and soft tissue infections
Gram +
AEs:
GI effects- n/v/d, abdominal pain- can disrupt cell division in GI tract
Myelosuppression- bone marrow suppression, leukopenia, granulocytopenia
Myopathy- rhabdomyolsis
Colchicine
5 drugs used for preventive migraine therapy
beta blockers depakote topamax TCAs CCBs
4- pentazocine, nalbuphine, butorphanol, and buprenorphine
When administered alone, produce analgesia
If given to a patient with pure opioid agonist- can antagonized the analgesia caused by the pure agonist
Pentazocine is the prototype
Agonist-antagonist
Activation results in analgesia and sedation
Underlies psychomimeic effects with certain opioids
Kappa receptors
o Only Cox 2 inhibition…
o Fewer AEs but may pose a higher risk of MI/stroke
Second Generation NSAIDs- Celebrex
Biologic DMARD- interferes with TNF
Etanercept, infliximab, adalimumab, golimumab, certolizumab
Produced mainly at sites of tissue injury, where it mediates inflammation and sensitizes receptors to painful stimuli
Present in brain, kidney, blood vessels, colon
mediates harmful processes
COX 2
AEs: Hepatic fibrosis Bone marrow suppression GI ulceration Pneumonitis
Methotrexate
Drug interactions: ASA, Indomethacin, sulfonamides
Probenecid
Indications: URIs PNA STDs UTIs Wound infections Endocarditis prophy Eradication of H. pylori in gastritis and PUD
Penicillins
Contraindications: Drug interactions: o Anticoagulants o Glucocorticoids o Alcohol o Non-ASA NSAIDs o ACEi and ARBs o Vaccines
ASA
AEs:
C. diff
Photosensitivity
Spontaneous tendon rupture- usually Achillies (especially in elderly and children)
• ***black box warning- those over 65 are at risk of severe tendon disorders- especially if they are also on steroids
Fluoroquinolones
AEs:
Increased incidence of c. diff- tell patients to report when they have 6-8 watery stools while on the antibiotic or if they see blood or pus in their stools
Development of an antabuse-like reaction- 30 min of alcohol ingestion (up to 3 days after completion of treatment)
• Severe vomiting, blurred vision, profound hypotension, facial flushing, SOB
Cephalosporins
Which antibiotic is the first-line therapy for CAP?
Macrolides
Drug classification that has the most drug-to-drug interactions?
Macrolides
COX 1 or 2 inhibitors? o Suppress inflammation o Alleviate pain o Reduce fever o Protect against colorectal cancer o ***but can cause renal impairment and promote MI/stroke by suppressing vasodilation***
2
Indications:
Staph aureus resistant to usual treatment with methicillin- MRSA
Vancomycin
Pediatric indication for use of fluoroquinolones?
Complicated UTI and pyelonephritis
MOA:
Alters transmission as serotonergic, dopaminergic, and alpha-adrenergic junctions
Affects serotonin 1B/1D receptors and can block inflammation associated with trigeminal vascular system by suppressing release of CGRT
Promotes constriction of cranial ateries
Ergot Alkaloids
Nursing Implications:
toxicity can cause ischemia from constriction of peripheral arteries (muscle pain and gangrene)
• Treat with nitrates to vasodilate
Ergot Alkaloids
AEs:
Dose-related GI symptoms (n/v/d)- most common SE
Development of c. diff
Rare cases of reversible hearing loss- starts with tinnitus
Elevated LFTs
Elevated platelets
Macrolides
Act as antagonists at mu and kappa receptors
Do not produce analgesia or any other effects
Principle use is to reverse respiratory and CNS depression caused by overdose by opioid agonists
Methylnaltrexone is used to treat opioid-induced constipation
• Naloxone (Narcan) is the prototype
Antagonist
Nursing Implications:
Can sometimes smell the antibiotic in patient’s urine- excreted unchanged in the urine
Crosses placenta and breast milk
Oral formulations can be destroyed by gastric acid
Penicillins
MOA:
Bacteriocidal- broad spectrum
Act by disrupting DNA replication and cell division
Fluoroquinolones
One of its main uses is to treat meningitis (3rd generation crosses the BBB)
Cephalosporins
cefotaxime
Retain a stain or resist decolorization with alcohol during culture and sensitivity
Gram +
Indications:
Suppression of inflammation
Fever reduction
Dysmenorrhea
Suppression of platelet aggregation
Cancer prevention (by inhibiting COX 2, which can promote tumors and metastases- colorectal CA expresses COX 2)
Drug of choice for RA and other inflammatory conditions
ASA
Which antibiotic requires monitoring for:
• Watch for altered response to meds metabolized by P450 enzymes
• Increased hearing loss risk
• ECG for QT interval (when abx used IV)
• Monitor for liver dysfunction- jaundice, n/v, abdominal pain, increased LFTs and bilis
Macrolides
Contraindications:
Reduces effectiveness of oral contraceptives
Diuretics- increased potassium wasting in the urine
Beta blockers- decreased bioavailability of atenolol
ASA, diuretics- ASA and diuretics compete with this antibiotic for renal tubular secretion so half-lives of drugs may be prolonged
Penicillins
Contraindications:
Many drug interactions
• Anticonvulsants, decreases effects of coumadin, interacts with xanthines (theophylline levels increase), antacids slow absorption of macrolides
• ***use caution when prescribing this with other drugs that have a narrow TI (digoxin and theophylline), can cause toxicity of these drugs
Use caution in patients with hepatic dysfunction
Adjust dose for patients with renal impairment
Can aggravate muscle weakness in patients with myasthenia gravis
Macrolides
What class of abx? cefepime
cephalosporin- 4th gen
Nursing Implications:
Can enter the CSF ONLY if the meninges are inflamed
Erythromycin is inactivated by gastric acid- other formulations are available
Compatible with breastfeeding but does cross placenta and is excreted in breastmilk
Macrolides
MOA:
Reduces activity of B and T lymphocytes, resulting in immunosuppression
Methotrexate
Commonly associated with GU and GI infections
Gram -
Activate mu receptors and kappa receptors
Produce analgesia, euphoria, sedation, respiratory depression, physical dependence, constipation and other effects
Divided into two groups- strong opioid agonists and moderate to strong opioid agonists
• Morphine is a strong agonist
• Codeine is moderate to strong
Agonist
Contraindications: Hepatic/renal impairment, sepsis, CAD, PVD, uncontrolled HTN, use of CYP3A4 inhibitors ***Pregnancy Category X!!!*** Triptans HIV protease inhibitors Azole antifungals
Ergot Alkaloids
Found in practically all tissues
Protects gastric mucosa, supports renal function (increases RBF), promotes platelet aggregation
“house keeping chores”
mediates beneficial processes
COX 1
Indications: Second-line therapeutic agents for: • Acute bronchitis • Acute otitis media • Pharyngitis Uses: • UTI (first-line in children) • Skin infections • Surgical prophy • Gram – meningitis (third or fourth gen) • Treat multiple resistant gram - infections
Cephalosporins
Irreversible inhibition of COX 1 and 2
ASA
Nursing implications:
Very expensive
Can treat serious infections with oral use and not require hospitalization
Fluoroquinolones
Increased incidence with use of cephalosporins
C. diff
When are cephalosporins used as first-line therapy? (5)
UTI in children Skin infections surgical trophy gram - meningitis multiple resistant gram - infections
Those whose cell walls lose a stain or are decolorized with alcohol
Gram -
First- and second- line treatment of c. diff
Metronidazole (1st) and oral Vancomycin (2nd)
Which drug has been associated with prolonged QTc interval?
Macrolides
