Antibiotics Sulfonamides, Penicillins, Cephalosporins, Tetracyclines, Floroquinolones, Aminoglycosides and other Anti-infectives
Objectives Discuss the rationale and nursing responsibility of culture and sensitivity testing Discuss the importance of penicillin, its action, spectrum, primary dosage forms, precautions of administration and name an example of each type. State the name and dosage form of penicillin effective against a penicillinase producing bacteria.
Objectives Explain the use of the broader spectrum antibiotics and cephalosporin. Discuss the danger of anaphylactic reactions, cause and treatment. Define super infection and antibiotic resistance. Develop a teaching plan for each of the antibiotics.
Antibiotics Uses Testing Bacteriostatic vs bactericidal Broad spectrum vs narrow spectrum
Antibiotic Superinfections Fungal, parastic, viral infections anaphylaxis
Sulfonamides First antibiotics to effectively treat infection Caused a sharp decline in morbidity and mortality related to infections Use has declined since the introduction of newer antibiotics
Sulfonamides Mechanism of Action Inhibits synthesis of folic acid Bacteriostatic Host defenses are essential for elimination of infection Microbial resistance Many bacteria have developed resistance Spectrum Broad spectrum Gram positive cocci (including MRSA), gramnegative bacilli, chlaydiae and some protazoans
Sulfonamides Uses UTI Topical treatment for burns to suppress bacterial colonization Superficial eye infections
Pharmacokinetics Absorption: Well absorbed orally Topically may cause systemic effects Metabolism and Excretion Metabolized by the liver Excreted by the kidneys. Renal excretion determines half-life
Adverse Effects Hypersensitivity reactions Mild: rash, drug fever, photosensitivity are common Stevens-Johnson syndrome Blood dyscrasias Nausea, vomiting diarrhea Stomatitis Crystalluria Photosensitivity
Interactions Intensify actions of warfarin, phenytoin and sulfonylurea type oral hypoglycemics by inhibiting hepatic metabolism
Contraindications Hypersensitivity Children <2 End of pregnancy Use cautiously in patients with renal impairment, hepatic impairment, bronchial asthma
Patient Teaching Increase fluid intake Take with a full glass of water Take on an empty stomach unless GI irritation occurs Photosensitivity Take full course of treatment
Combination Drugs Trimethoprim/Sulfamethoxazole Inhibit sequential steps in tetrahydrofolic acid production Selectively toxic to bacteria The two drugs potentiate each other Resistance to the combination is less than to the two drugs alone Trade names: Bactrim, Contrim, Septra
Jason Williams is a 75-year-old African American man. He is diagnosed with an acute exacerbation of chronic bronchitis. The physician would like to give Mr. Williams a sulfonamide to treat his exacerbation. Discussion: 1. What information should the nurse obtain from Mr. Williams before the physician sees him? 2. The physician diagnoses Mr. Williams with an acute exacerbation of chronic bronchitis. The physician would like to give Mr. Williams Bactrim DS one tablet every 12 hours for 14 days. What should the nurse tell Mr. Williams about the prescription before letting him leave the physician s office? 3. Mr. Williams calls the physician s office after 2 days of taking the medication. He complains of red bumps on his face, neck, and extremities. What should the nurse tell Mr. Williams?
True/False 1.Anorexia is an example of a mild adverse reaction of sulfonamides. 2.Leukopenia is a decrease in the number of red blood cells. 3.Thrombocytopenia is a decrease in the number of platelets. 4.Cranberries are thought to attract bacteria to the walls of the urinary tract. 5.The nurse protects the patient with severe leukopenia from individuals who have an infection.
1. The skin becomes more sensitive to when taking sulfonamides. 2. When or silver sulfadiazine is used in treating burns, the treatment regimen is outlined by the primary health care provider or the personnel in the burn treatment unit. 3. An older adult may be hesitant to increase oral fluid intake because of fear of. 4. The sulfonamides are used with caution in patients with renal impairment, hepatic impairment, or. 5. When diabetic patients are prescribed sulfonamides, they are assessed for a possible reaction.
Penicillins First large-scale antibiotics used to treat infection Four groups Natural penicillins Penicillinase-resistant penicillins Aminopenicillins Extended spectrum penicillins Nearly ideal antibiotics Weaken the cell wall
Bacterial Cell Wall Rigid, permeable, mesh-like structure that lies outside the cytoplasmic membrane Pressure inside the cytoplasmic membrane is high Rigid cell wall prevents expansion
Penicillin Action Inhibit enzymes critical to cell wall synthesis Disrupt cell wall synthesis Promote active destruction of cell wall Bactericidal Only active against bacteria undergoing growth and division
Natural Penicillin Drug attaches to cell Beta-lactam ring binds with PBP s Cell wall breaks and cell dies Penicillinase= resistance Narrow spectrum Penicillin G Penicilllin V
Pen-G First Penicillin available Spectrum Most gram positive bacteria Gram negative cocci (neisseria meningitidis and strains of Neisseria gonorrhoeae Anaerobic bacteria Spirohetes (e.g. treponema pallidum)
Penicillin Absorption Pen G not stable in acid not given orally Pen V, Pen VK : acid stable. May be taken with meals. IM different salts absorbed at different rates Pen G is rapid Pen VK only for IV Elimination Via kidneys primarily as the unchanged drug Side effects Pen G least toxic of all antibiotics, among the safest of all medications
Beta-lactamases Enzymes that cleave beta-lactam ring Render penicillin and beta-lactam antibiotics inactive Bacteria produce a variety of beta lactamases Penicillin specific beta-lactamases are called penicillinase
Beta lactamase inhibitors Ampicillin/sulbactam (Unasyn) Amoxicillin/clavulanic acid (Augmentin) Ticarcillin/clavulanic acid (Timentin) Pipracillin/tazobactam (Zosyn)
Penicillinase Resistant Penicillins Narrow spectrum Staph aureus and epidermidis Semi-synthetic Highly resistant to Beta-lactamases Dicloxacillin sodium Nafcillin Oxacillin sodium
Drug Resistance MRSA Resistant to: Methicillin, oxacillin, penicillin, amoxicillin VRE
Aminopenicillins Broad spectrum Ampicillin, amoxicillin Increased ability to penetrate gram negative cell envelope Readily inactivated by beta-lactamase More slowly excreted by kidneys
Extended Spectrum Penicillins Antipseudomonal penicillins Ticarcillin Carbenicillin Indanyl Pipericillin Susceptible to beta-lactamases Used primarily for infection with p. aeruginosa. Used with an aminoglycoside for pseudamonas infection.
Adverse Reactions Glossitis Gastritis Nausea, vomiting Diarrhea and abdominal pain
Interactions Decrease effectiveness of Oral contraceptives Tetracylines Increased effectiveness Anticoagulants Beta-blockers Increased risk of anaphylaxis
Superinfections May develop rapidly Potentially life threatening Occur with oral administration of PCNs Elderly, chronically ill, prolonged treatment with penicillin E.g. pseuodmembranous colitis Overgrowth of c. dificile Symptoms: diarrhea, bloody diarrhea, rectal bleeding, fever, abdominal cramping Candidiasis, moniliasis
True/False 1. Penicillinase is a chemical that binds with penicillin and protects the penicillin from destruction. 2. In viral infections, penicillin may be prescribed as a prophylaxis. 3. Hematopoietic changes, such as anemia, are adverse reactions that may occur with use of penicillin. 4. Phlebitis occurs in patients who have been administered penicillin intramuscularly. 5. Ampicillin decreases the effectiveness of birth control pills (with estrogen).
1. shock is a severe form of hypersensitivity reaction which occurs more frequently after parenteral administration of penicillin. 2. colitis, a commonly occurring bacterial superinfection, may occur after 4 to 9 days of treatment with penicillin or as long as 6 weeks after the drug is discontinued. 3. Certain bacteria have developed the ability to produce enzymes called, which are able to destroy the beta-lactam ring. 4. A penicillin is used as initial therapy for any suspected staphylococcal infection until culture and sensitivity results are known. 5. Bleeding risks may increase when large doses of penicillin are taken with.
Lori Jenkins is a 6-year-old Caucasian girl. She presents to the physician s office today with bilateral ear pain, nasal congestion, cough, and a low-grade fever. Her mother reports she is not taking any medications and has no allergies that she is aware of at this point. The physician writes a prescription for amoxicillin 250 mg/5 ml, give 2 teaspoonfuls 3 times a day for 10 days. 1. Lori s mother is concerned that Lori may have an allergic reaction to the amoxicillin. What signs or symptoms should the nurse tell Lori s mother to look for that may indicate an allergic reaction has occurred? 2. What should the nurse tell Lori s mother about oral suspensions? 3. What should the nurse tell Lori s mother about the prevention of anti-infective resistance?
Cephalosporins Beta lactam antibiotics similar to penicillin Bactericidal Often resistant to beta-lactamases Active against a broad spectrum of bacteria Most widely used group of antibiotic
Cephalosporins Action Bind to PBPs and disrupt cell wall synthesis and activate autolysins Resistance 1 st generation destroyed by betalactamases 2 nd generation les sensitive to destruction 3 rd and 4 th generation highly resistant
Cephalosporins 1 st Generation Cefadroxil, cefazolin, cephalexin, cephadrine 2 nd generation Cefaclor, cefmetazole, cefotetan, cefoxitin, cefprozil, cefuroxime 3 rd generation Cefdinir, cefditoren, cefixime, cefoperazone, cefotaxime, ceftriaxone 4 th generation cefepime
Cephalosporins Uses Respiratory infections Otitis media Bone/joint infections Genitourinary infections Perioperative prophylaxis Administration Only 12 out of 22 can be given orally Only cefuroxime can be given orally AND via injection Elimination: Renal via glomerular filtration and active tubular secretion
Cephalosporins Drug interactions Probenicid delays renal excretion, prolonging effect of cephalosporin Alcohol: cefmetazole, cefoperazone, cefotetan induce a state of alcohol intolerance. Cefmetazole, cefoperazone and cefotetan promote bleeding. Use cautiously with other drugs that promote bleeding
Cephalosporins Adverse effects Generally well tolerated, rare serious effects, pain at injection site Allergic reactions most frequent AE Contraindications History of allergies to PCN or cephalosporins Use cautiously in renal disease, hepatic impairment, bleeding disorders, pregnancy
Luis Labra is a 65-year-old Hispanic man. He presents to the emergency department today with increased shortness of breath, cough, and a low-grade fever. His current medications are warfarin (Coumadin) 5 mg take as directed and metoprolol 50 mg twice daily. He is admitted to the hospital and the physician writes an order for Mr. Labra to receive ceftriaxone (Rocephin) 1 g every 12 hours via IV infusion. 1. Before administering the ceftriaxone to Mr. Labra what information should the nurse obtain from the patient? 2. He reports upset stomach after taking penicillin a long time ago. Is this a true allergy, and should Mr. Labra not receive the ceftriaxone? 3. Mr. Labra is feeling better but is to continue to receive cefdinir (Omnicef) 300 mg by mouth twice daily for 7 days. What should the nurse tell Mr. Labra and his family about the Omnicef?
1. Progression from the first-generation to the fourth-generation drugs shows a decrease in the sensitivity of gram-negative microorganisms and an increase in the sensitivity of gram-positive microorganisms. 2. Hypersensitivity reactions may occur with administration of the cephalosporins and may range from mild to life threatening. 3. The nurse should administer cephalosporins even if the patient has a history of allergies to penicillins. 4. A disulfiram-like reaction occurs if aerated water is consumed within 72 hours after certain cephalosporin administration. 5. Signs of redness near the needle insertion site may indicate phlebitis or thrombophlebitis.
1. The nurse warns the patient that at the time the drug is injected into the muscle, there may be a or burning sensation and the area may be sore for a short time. 2. anemia is caused due to deficient red blood cell production. 3. Any changes in the fluid intake-and-output ratio or in the appearance of the urine on administration of cephalosporins may indicate. 4. If renal impairment is present, a lower dosage and monitoring of blood levels are indicated. 5. A test is performed when blood and mucus are detected in the stool frequently.
Tetracylclines, macrolides, and lincosamides Broad spectrum antibiotics
Tetracyclines Demeclocycline Doxycycline Oxytetracycline Tigecycline
Tetracyclines Natural and semisynthetic Action Inhibit bacterial protein synthesis Spectrum Use Broad spectrum against both gram positive and gram negative e.g. rikettsia, spirochetes, brucella, chlamydia, mycoplasma Rickettsial diseases, infections caused by chlamydia trachomatis, brucellosis, cholera, mycoplasma pneumonia, Lyme disease, anthrax, gastric infection with H. pylori. Topically for acne
Tetracyclines Absorption Binds with calcium, iron, magnesium, aluminum and zinc Elimination Eliminated by kidneys and liver Adverse Effects GI Irritation Bind to calcium in developing teeth causing yellow or brown discoloration Suppression of long bone growth in premature infants Hepatotoxicity Renal toxicity
Tetracyclines Interactions Antacids or supplements containing aluminum, calcium, magnesium, iron, zinc decrease absorption of tetracycline Decrease effectiveness of Oral contraceptives Increase risk for bleeding with anticoagulants Increased risk of toxicity with digitalis
Contraindications Pregnancy Lactation Younger than 9 Use with caution in renal and hepatic dysfunction
Macrolides Broad spectrum Inhibit bacterial protein synthesis Macrolides= very big molecules Erythromycin oldest member of the family Azithromycin, clarithromycin, dirithromycin, troleandomycin are all erythromycin derivatives
Macrolides Uses Erythromycin is used as an alternative for those allergic to Penicillin to treat respiratory tract infections caused by strep pneumoniae DOC for Legionella pneumonia, bordetella pertussis, acute diphtheria, Acne and skin infections URI caused by H. influenzae
Macrolides Adverse Reactions Nausea, vomiting, diarrhea Abdominal pain or cramping Use cautiously in patients with liver dysfunction, myasthenia gravis Metabolism and Excretion Emycin metabolized by liver and excreted in bile. 10-15% excreted unchanged in urine
Lincosamides Inhibit protein synthesis Used to treat serious infections in conjunction with other antibiotics Clindamycin, lincomycin Clindamycin may cause severe pseudomembranous colitis
Adverse Reactions and Contraindications AE: GI Skin Blood dyscrasias Contraindications and Precautions Minor infection Concurrent use of cisapride or pimozide Use caution with GI, renal, liver disorders or with myasthenia gravis
Maria Lopez is a 24-year-old Hispanic woman. She presents to the physician s office today seeking treatment for her acne. Her only medication is Ortho Tri-Cyclen Lo. The physician writes Ms. Lopez a prescription for doxycycline (Doryx) 150 mg once daily. 1. What should the nurse tell Ms. Lopez about taking oral contraception with Doryx? 2. What adverse reactions should the nurse discuss with Ms. Lopez? 3. How should the nurse tell Ms. Lopez to take the Doryx?
Tetracyclines should be given only after having a proper meal. Food impairs the absorption of lincomycin. The minocycline (Minocin) and oxytetracycline (Terramycin) drugs can be taken with food. The macrolides inhibit protein synthesis in susceptible bacteria, causing cell death. In a patient taking an aminoglycoside, if constipation occurs, the nurse should save a sample of the stool and test it for occult blood using a test such as Hemoccult.
is a drug related to the lincomycin which can cause the patient's eyes to have difficulty focusing and accommodating to light. are contraindicated in infants less than 1 month old. Uncomplicated urethral, endocervical, or rectal infections caused by Chlamydia trachomatis can be cured using. is a disease that affects the myoneural junction in nerves and is manifested by extreme weakness and exhaustion of the muscles. A macrolide when administered with causes increased serum levels.
Fluoroquinolones Interfere with synthesis of DNA Prevents cell reproduction Rapidly Bactericidal
Fluoroquinolones Ciprofloxacin, gatifloxacin, lomefloxacin, moxifloxacin, ofloxacin Uses Lower respiratory infection Bone and joint infections UTI Skin infections STD Ophthalmic infections
Fluoroquinolones Adverse effects Nausea, diarrhea, abdominal discomfort Dizziness, headache, restlessness, confusion Yeast infections Tendon rupture (usually of Achilles tendon), rare Photosensitivity Hepatic metabolism, renal excretion
Fluoroquinolones Interactions Absorption is reduced by aluminum or magnesium antacids, iron, zinc, sucralfate and mild products Increased effects of: theophylline, anticoagulants Cimetidine interferes with elimination of antibiotic NSAIDS increase risk of seizure activity
Aminoglycosides Action Block protein synthesis Disrupt cell wall functioning Bactericidal Elimination primarily by the kidneys Amikacin, gentamicin, kanamycin, neomycin, streptomycin, tobramycin Uses Gram negative infections Reduction of intestinal flora prior to surgery
Aminoglycosides Adverse effects Nausea, vomiting, anorexia Rash, urticaria Nephrotoxicity, ototoxicity Neruotoxicity Contraindications Pregnancy and lactation Not for long term use Myasthenia gravis
Linezolid Zyvox First drug of a new class Class: oxazolidinone Spectrum: Active against multi-drug resistant gram positive pathogens Bacteriostatic inhibitor of protein synthesis Side effects: diarrhea, nausea, headache Oral formulation CANNOT be used with those who have PKU
Carbapenems Action: Inhibit synthesis of bacterial cell wall Meropenem, Imipenem-cilastatin, ertapenem Use: Serious infections, community acquired infections Contraindications
Vancomycin Potentially toxic Used only for serious infections Inhibits cell wall synthesis Promotes bacterial lysis Spectrum Only active against gram positive organisms Eliminated unchanged by the kidneys
Vancomycin Adverse effects Ototoxicity nephrotoxicity Red man syndrome thrombophlebitis
Ready for Testing? When would antibiotics be used in viral, parasitic or fungal infections? Describe symptoms and treatment of anaphylaxis. Name 3 broad spectrum antibiotics. Name the action and uses of the different classes of antiobiotics. What is antiobiotic resistance and why and how does it develop?
Define superinfection, cause and treatment. Drugs to know: Tetracycline, Septra, Amoxicillin, cefazolin, cefaclor, bicillin LA, ampicillin, mafemide, ciprofloxacin, cephtriaxone, cefazolin, cephalexin, Cloxacillin, nafcillin, ampicillin, gentamicin, Silvadene Patient teaching
A 60-year-old patient admitted to the clinic for a severe ear infection is being treated with penicillin. One morning during your first round, the patient reports that he is feeling nauseous and that his stomach hurts. Apart from the ear infection, the client has no known health problems. What is the possible cause of the patient s symptoms? What is this condition known as? What will be your next step to ensure that the patient suffers no adverse reactions to the administered drug?
2. You are required to care for a 70-year-old chronically ill patient who has been receiving penicillin for a long time. a.what adverse reaction(s) is this client more prone to? b.what assessment findings are most important in determining care for managing the adverse reaction(s)? c.how can adverse reaction(s) be managed?
. An 18-year-old woman who had been prescribed penicillin G benzathine for rheumatic fever has come in for a follow-up assessment. In response to whether she completed the course for the prescribed antibiotic, she says that she discontinued it 3 weeks early. She does not wish to take any more medication because she believes her symptoms have disappeared, and she is now feeling well. a.is there a lapse in self-care by the patient? b.how will you ensure that the patient adheres to the course of the drug?
1)A patient is admitted to the hospital with a urinary tract infection. The analysis of samples collected from the patient indicates that the infection is caused due to bacterium Escherichia coli. a)which antibiotic drug can be used by the patient? b)what adverse reactions can be caused by this antibiotic drug?
A patient is admitted to the hospital with Stevens-Johnson syndrome (SJS). What reactions should the nurse monitor in the patient? What interventions should the nurse perform?
) The nurse is caring for a patient receiving sulfonamide therapy. a) What nursing interventions can be taken to promote optimal response to the therapy? b) What points should be included by the nurse in the teaching plan?
A patient is admitted to the hospital due to a severe stomachache. The patient has been diagnosed with appendicitis and is about to be operated on. At what stage should the nurse use the cephalosporins? Give reasons for your answers.
1)A patient in the hospital has been given cephalosporins and is having frequent liquid stools. a.what does this indicate? b.what are the nursing interventions when a patient receiving cephalosporin develops diarrhea?
An elderly diabetic patient has come to the hospital for a routine checkup and is to be assessed for cephalosporin therapy. What information should the nurse include while obtaining the health history of the patient before administering cephalosporin? The patient has been non-ambulatory for 2 weeks due to a fall. He has been prescribed cephalosporin, which the nurse injects in the lateral aspect of the thigh. Considering the client s age and condition, what precautions should the nurse take?