NURS 1950 Antibiotics and other Agents

1. NURS 1950Antibiotics and other Agents Metropolitan Community College Nursing Program Nancy Pares, RN, MSN

2. In the beginning……. • Before Antibiotics • Infections treated topically with ‘poultice’ or surgically removed • 1936…Sulfonamide discovered • Beginning of understanding of microbes • 1941…Penicillin introduced • WWII had great results with high volume data • Present …. • Man vs. microbe= resistant pathogens

3. Peak effect • 15-30 min after infusion has begun • Trough effect • Lowest point of medication effect • Draw blood just before the next scheduled dose

5. Chain of infection….recall

7. Objective 1: Identify the body’s natural defenses against infections • Barriers/prevention • Intact skin, adequate nutrition, respiratory cilia, immune system • Seek and Destroy • WBC, adequate blood supply, intestinal flora, vaginal flora, stomach acids

8. Objective 2: Describe factors that increase the susceptibility of the body to infection Virulence of the pathogen Number of pathogens Chronic illness Poor nutrition Diseases/drugs that decrease the immune system Entry point Super infections

9. Host Factors • Status of immune system • May need prophylactic therapy • Location of the infection • Many drugs do not cross blood brain barrier • Extent of inflammation • Decrease circulation of drug • Age: metabolization of drug • Pregnancy: risks to fetus vs. benefit of drug • Genetics: enzyme deficiencies do not allow antibiotics to clear system

11. Obj. 3: Name the lab tests done to identify the invading pathogen • Should be done before antibiotic initiated • Microscopic examination • Urine, stool, blood, spinal fluid, sputum, purulent drainage • Identify the organism and test with antibiotics • Culture and sensitivity testing • Preliminary results within 24 hours • Final results in 2-3 days

12. Obj. 4: Identify factors utilized to select an appropriate antibiotic Covered in objective 2

13. Obj. 5 Explain what resistance means and the various types of resistance • Passive immunity • A person has been given vaccine • Active immunity • Has had the disease • Acquired resistance • Bacteria have randomly mutated and can transmit mutated bacteria to others • Healthcare practitioners role • Use antibiotics when indicated • Prophylaxis: deep tissue injury, prosthetic heart valves

14. NOTE • Antibiotics do not create mutations

15. Obj. 6: Define narrow spectrum and broad spectrum • Narrow • Effective on limited number of organisms • Broad • Effective on many organisms; often used first • Bacteriocidal • Kills • Bacteriostatic • Prevents growth and reproduction

16. Obj. 7: Describe adverse reactions to antibiotics • Hypersensitivity • Can result in anaphylactic shock/death • 15% of penicillin users • Treat with Benedryl, corticosteroids, epinephrine • Cross sensitivity • When antibiotics are closely related chemically • Organ toxicity • Liver, kidneys, CNS, GI is most common • Vancomycin highly nephrotoxic • Gentamycin highly ototoxic

17. Adverse reactions con’t • Hematotoxicity • Chloramphenicol • Causes aplastic anemia • Bone marrow cannot make red blood cells

18. Obj. 8 Discuss the penicillins and identify specific penicillin preparations • Action/use • Kill bacteria by disrupting cell wall; chemical make up responsible is beta lactam ring— • some bacteria secrete enzyme that splits the beta lactam ring allowing the bacteria to become resistant • Chemical modifications • Penicilinase resistant, broad spectrum, extended spectrum • Treatment of pneumonia, skin, bone and joint infections, blood infections, gangrene, meningitis

19. Penicillins cont • Routes • PO, IM, IV • Adverse effects • Hypersensitivity most common • Nursing considerations • VS, assess previous reactions, lab (electrolytes, renal function, ECG, Observe for IV reaction within 30 min; client teaching; decrease effects of contraceptives; take on empty stomach • Pen G Procaine—not given IV= lethal • Prototype: Pen G Potassium

21. Obj.9 Discuss various cephalosporin preparations • Action/Use • Bacteriocidal by attaching to penicillin binding proteins to inhibit cell wall synthesis • Gram negative infections and when less expensive penicillins are not tolerated; 5-10% of people allergic to penicillin are also allergic to cephalosporins • Adverse reactions • Hypersensitivity; kidney toxicity • Prototype—Cefotaxime (Claforan)

22. Cephalosporin classifications • First generation • Most effective against gram neg; beta lactamase producing organisms usually resistant • Second generation • More potent, broader spectrum, moderately resistant to beta lactamase organisms • Third generation • Longer duration of action, resistant to b-lactamase • Drugs of choice for pseudomonas, klebsiella, neisseria, salmonella and H. influenza • Fourth generation-treat CNS infections • Use: gram + cocci; gram - bacilli

23. Cephalosporins • Nursing considerations • Assess for bleeding disorders-check PT levels • Interferes with Vit K metabolism • Assess kidney and liver function labs • Important in Vit K production • Assess concurrent meds: (NSAIDS) • Monitor I&O • Assess GI symptoms • Client teaching • Cultured dairy (superinfection prevention); avoid alcohol use, complete full RX; IM inj. painful

24. Obj. 10 Discuss tetracycline , including nursing implications • Action/Use • Bacteriostatic; inhibits protein synthesis to slow microbial growth • Rocky Mtn Spotted fever, typhus, cholera, Lyme disease, peptic ulcers (caused by H. pylori), chlamydial infections • S/E • n/v, diarrhea, photosensitivity, permanent discoloration of teeth <8 yo

26. Tetracycline con’t • Nursing considerations • Avoid use <8 yo, avoid sunlight/UV exposure; monitor labs (CBC, liver function, kidney function) • Teach importance of oral and perineal hygiene due to super infections • Do not take with milk products, iron supplements, or antacids; wait 1-3 hrs before taking antacids; wait 2 hrs before and after taking lipid lowering drugs (Ca+ and iron bind with tetracycline) • Decreases effectiveness of oral contraception • Prototype: tetracycline

27. Obj. 11 Describe the uses, s/e, nursing implications of the various aminoglycosides • Action/use • Bacteriocidal; inhibits protein synthesis • Aerobic gram neg bacteria (e. coli, seratia, proteus, klebsiella, pseudomanas); administered with other antibiotic for entercocci infections. • S/E • Irreversible ototoxicity, nephrotoxicity, respiratory paralysis • Prototype: Gentamycin (Garamycin)

28. Aminoglycosides cont • Nursing considerations • Monitor for ototoxicity (How?) • Monitor for nephrotoxicity (How?) • Provide optimal oral hygiene • IV administration should be done slowly • Poorly absorbed via GI—only route is IV • Monitor peak and trough levels for toxicity

30. Obj. 12 Discuss uses of quinolones and macrolides • Quinolones/fluoroquinolones • First introduced in 1962 • Currently four generations • Macrolides • Low doses-bacteriostatic • High doses-bacteriocidal • Prototype: e mycin

31. Quinolones • Action/Use • Bacteriocidal;inhibit enzymes (DNA gyrase and topoisomerase) to affect DNA synthesis;gram neg microbes • Respiratory, GI, GU tracts; skin and soft tissue; newer agents very effective against anerobes • S/E/route • n/v; ADVERSE: dysrhythmias,liver failure and CNS changes; not used in pregnancy; caution in children; oral BID • Prototype:Ciprofloxicin (Cipro) • Most common= levaquin

32. Quinolones • Nursing considerations: • Assess hypersensititivity; report neurologic effects • Phototoxicitity • Don’t take with vitamins/mineral supplements (or wait 2 hrs before and after • Monitor labs • I & O • Take all the prescription

33. Macrolides • Action/Use • Binds to bacterial ribosome to inhibit synthesis (act inside cell); bacteriostatic; effective against gram + and -;treats whooping cough, • Legionaire’s disease, H. influenza and Mycoplasma pneumoniae • Newer drugs synthesized from erythromycin—less GI disturbance • S/E—very few • Prototype: erythromycin (E-Mycin)

34. Macrolides • Nursing considerations • Do not use in pregnancy • Assess history of hypersensititivity • Monitor labs (liver and kidney, INR) • Macrolides decrease warfarin metablism and excretion • Photosensitivity • Complete the course of treatment

35. # 13 Describe Misc. drugs • Clindamycin (Cleocin) • Grm + and – effectiveness • Use: oral infections • Contraindication: hypersensitivity • Limited use due to association w pseudomenbranous colitis

36. Misc. agents cont • Sulfonamides • Action:bacteriostatic, broad spectrum, used for UTI • Classified by route of administration • Systemic and topical • Systemic • Sulfisoxazole (Gantrisin) • topical • Sulfadoxine (Fansidar)- not 1st choice drug • Contraindicated in pregnancy and infants < 2 years (promotes jaundice);low soluability causes crystals in urine

37. Misc. agents • Vancomycin ( Vancocin) • Reserved for severe infections; most effective with MSRA; need peak and trough labs • Sensititivity reaction: hypotension and rash with rapid IV infusion (Red Man Syndrome) • Imipenim (primaxin)—carbapenem category • Bacteriocidal; preparation specific for IV vs IM • Stable for 4 hrs; synergistic effects with aminoglycosides • Use; septicemia/bacterial meningitis

38. Misc agents • Ketolides • Use: respiratory infections • Low incidence of adverse effects • Glycylcyclines • Use: complicated skin infections; MSRA

39. 14: patient education for anbx • Nursing Dx • Pain related to infection • Infection • Hyperthermia • Risk for injury related to adverse drug effects • Deficient knowledge related to drug therapy • Risk for deficient fluid volume r/t fever, diarrhea from adverse drug effect • Risk for non compliance r/t deficient knowledge, cost of drug, drug effects

40. Planning • Client will • Report diminished signs and symptoms of infection; decreased fever and fatigue; increased appetite • Be free from or experience minimal adverse effects • Verbalize understanding of the drugs use, adverse effects and required precautions • Demonstrate proper self administration

41. Implementation • Monitor vs and symptoms of infections • Monitor hypersensitivity reaction • Monitor for severe diarrhea • Admin drug as ordered • Monitor for superinfection • Precaution regarding OTC • Monitor for photosensitivity • Determine food and drug interactions • Monitor IV site

42. Evaluation • Patient • reports diminished signs and symptoms of infection, decreased fever • Is free from or experiences minimal adverse effects • Verbalizes and understanding of the drugs use, effects and precautions • Demonstrates proper self admin.

43. 15: Antitubucular drugs • Tuberculosis: • Cause: • Mycobacterium tuberculosis • Incidence: • Treatment: prolonged due to cell wall resistance to penetration by anti infective drugs • Multiple drug concurrently • Rifampin: used for H influenza

44. Tuberculosis cont • Isoniazid (INH) • Action: • Inhibits synthesis of cell wall • Use: • tuberculosis • S/E • Numbness of hands, feet; rash; fever • Contraindicated: hepatic disease; do not take with antacids

45. 16: antifungal agents • General Action: • Inhibit ergosteral synthesis • Amphoericin B (Fungizone) • Systemic • New class: echinocandins • Used for systemic mycoses • Caspofungin: treats aspergilosis

46. Antifungals • Azoles • Fluconazole (Diflucan) • Action/use • Penetrates most body membranes; interferes with synthesis of ergosterol • Nystatin (Mycostatin) • Superficial antifungal • Swish and swallow • Glycemic control changes occur • Do not use intravaginally with pregnancy or lactating moms

47. 17: Antivirals • Nonnucleoside reverse transcriptase inhibitors (NRTI) • Action: binds to viral transcript and dis allows the DNA action • Prototype: efavirenz (Sustiva) • Nucleoside and nucleotide reverse transcriptase inhibitors (NNRTI) • Action: creates a defective DNA by replacing one of the nucleotides • Prototype: Zidovudine (AZT)

48. Antivirals cont • Protease inhibitors • Lopinavir (Kalentra) • Combination drug of lopinavir and ritonavir • Action: inhibits hepatic breakdown of lopinavir • Fusion inhibitor: • Action: blocks fusion of HIV viron to DC4 receptor

50. 18: Nursing process for antivirals • Assessment