ANTIMICROBIALS Antibacterials/ Antimicrobials Kill bacteria and microbes that cause infections or infectious disease Inhibit bacterial growth

th Produced or synthesized from other microorganisms DO NOT KILL VIRUSES!!! Terminology Bacteriostatic SLOWS growth of bacteria o Tetracyclines & Sulfonamides Bacteriocidal KILLS bacteria o Penicillins & Cephalosporins Narrow Spectrum Primarily effective against one type of organism Broad Spectrum Effective against gram (-) & gram (+) organisms o Used if no C&S result Culture & Sensitivity (C&S) Detects the infective microorganism in the blood & what drug can kill it Culture Organism causing the infection Sensitivity antimicrobial the organism is sensitive to Draw before antimicrobial administration Human Defenses & Antibiotics Hosts defense mechanisms Age Nutrition Circulation Organ Function WBC Count Immune Globulins Resistance Lessened antibiotic effect d/t misuse o Used on viruses or wrong bacteria/fungus o Mutant bacteria survive antibiotic use o Taken incorrectly Combating Resistance o New classes of drugs Antibiotic Resistance Disabler o Bacterial Vaccines (pneumococcal) o Client Teaching Superinfection Secondary infection: when normal flora are killed Sites: mouth, skin, respiratory tract, vagina, intestines Fungal or bacterial Broad spectrum >1 week THIS IS CONSIDERED AN ADVERSE REACTION. NOTIFY THE PHYSICIAN ASAP!!!

Dose Adjusting Organ Toxicity: o Organs Effected: Liver Kidney Ears o Labs: CLCr BUN Cr LFTS AST ALT o Assess: Jaundice Urine Output Auditory Checks Critically-Ill Patients o Immunocompromised Antibiotic Complications Clostridium difficile colitis (C. diff) o Antibiotics kill normal intestinal bacteria C. diff grows out of control o Swelling & irritation of large intestine o Diarrhea, fever, cramps & death Death is very rare from C. diff Generation Each group of antibiotics Each is effective against a BROADER SPECTRUM Cephalosporins o 4 Generations PENICILLINS (PCN) Penicillins (Basic) Broad-Spectrum PCNs Penicillinase-Resistant PCNs Extended-Spectrum Penicillins *Beta-lactamase Inhibitors SEE TABLE 29-3 Kee Book Basic Penicillins (PCN) Beta-lactam antibiotics Interfere with and inhibit bacterial cell wall synthesis Narrow Spectrum Bacteriostatic & bacteriocidal o Dose Dependant Indications of Use: o Staphylococcal Infections o Severe Wound & Respiratory Infections Examples: o Penicillin G procaine o Bicillin

Broad-Spectrum PCNs Aminopenicillins Bactericidal Work against gram (+) and gram (-) bacteria o E. coli, salmonella, influenza Indications of Use: o LRI, otitis media, sinusitis, skin infections, UTI Examples: o Amoxicillin Most RXd PCN derivative Effect when taken with Aspirin Probenecid

Effect when taken with Tetracycline Erythromycin Labs: serum AST, ALT, BUN, Cr Food: effect with acidic fruits and juices Side Effects: N/V/D, rash, edema Adverse Reactions: Blood dyscrasias, hemolytic anemia, bone marrow depression, respiratory distress Ampicillin

Penicillinase-Resistant PCNs Antistaphylococcal Penicillins Bactericidal Work against MOST gram (+) bacteria TX for penicillinase-producing Staph aureus Examples: o Cloxacillin o Unipen Extended-Spectrum Penicillins Antipsuedomonal Penicillins Bacteriocidal & gram (-) o Psuedomonas aeruginosa & Klebsiella pneumonia o Broad spectrum Indications of use o TX bone, joint, skin, respiratory tract infections, and UTIs Examples: o Piperacillin o Ticarcillin *Beta-lactamase Inhibitors Examples: o Clavulanic Acid o Sulbactam o Tazobactam Indications for use o Penicillinase-producing Staph aureus Combined with broad-spectrum antibiotics o Extends their antimicrobial effect Adding Clavulanic Acid intensifies the effect of amoxicillin (Augmentin) PO: Amoxicillin-clavulanic acid (Augmentin) o Sinusitis, pneumonia, bronchitis IM/IV Piperacillin-tazobactam (Zosyn)

o o

UTI, bone & joint infections, stomach infections, skin infections & pneumonia Reduce dose in renal insufficiency

Drug Interactions: Amoxicillin & Ampicillin effectiveness of oral contraceptives K+ supplements serum K+ levels when taken with Potassium PCN G or V PCN & Aminoglycosides mix in IVF THE ACTIONS OF BOTH ARE INACTIVATED! Safety: PCN 5-10% Cross Allergenicity to Cephalosporins Serum BUN/Cr, LFTs & Urine Output o Decrease dose with renal dysfunction Side Effects: o Rash Itching, fever, chills, N/V/D Adverse Reactions: o Hypersensitivity, superinfection, laryngeal edema, wheezing, hypotension Nursing Interventions: C&S before med administration Monitor for bleeding Observe closely for allergic reaction o 1st and 2nd dose (epinephrine) o Medical Alert bracelet fluid intake Assess for superinfection o Stomatitis, vaginitis CEPHALOSPORINS Beta-lactam structure o Semi-synthetic Inhibits bacterial cell wall synthesis o Bactericidal o Similar to PCN Indications of Use: o Respiratory, urinary, skin, bone, joint & genital infections Generations: o 1st Generation Gram (+) bacteria E. coli, Klebsiella Cephalexin Cefazoin o 2nd Generation Gram (+) & gram (-) Neisseria gonorrhorae, Haemophilus influenza, Neisseria meningitis Cephaclor Cefoxitin o 3rd Generation Gram (+) & gram (-) pseudomonas aeruginosa Cefoperazone Ceftriaxone o 4th Generation Gram (+) & gram (-) streptococci, staphylococci Cefepime o ALWAYS DO THE 3 CHECKS THESE DRUGS HAVE VERY SIMILAR NAMES!!! Pharmacokinetics: o Few PO; most IM, IV Side Effects: o N/V/D, GI distress, H/A Adverse Reactions: o With High Doses INCREASED BLEEDING o Nephrotoxicity (in CRF/ARF) Drug Interactions:

Alcohol may cause flushing, dizziness, H/A, N/V, muscular cramps Oral Contraceptives effect Uricosurics Cephalosporin excretion (i.e. Probenecid) Can lead to accumulation and toxicity Nursing Interventions: o Assess for allergic reaction o C&S before therapy o Assess renal and liver function o Monitor for superinfection o Monitor bleeding studies, VS, UO Safety: o KEEP OUT OF THE REACH OF CHILDREN Client Teaching: o Report S/S of superinfection Instruct to ingest buttermilk or yogurt for prevention with long-term use o Complete course of medication o Use childproof caps and store/keep out of reach of children o Infuse all meds 30 min o Report all side effects o o o

Penicillin (PCN) Substitutes Macrolides Lincosamides Glycopeptides Ketolides Broad Spectrum Antibiotic effectiveness similar to PCN Used in PCN allergic patients Macrolides Broad spectrum: some gram (-), most are gram (+) o Binds to ribosomal units and inhibits protein synthesis o In low to moderate doses BACTERIOSTATIC o In high doses BACTERIOCIDAL Indications of Use: o STIs, GI, respiratory, skin, sinus infections o Commonly used in clients w/ PCN allergies Drugs: o Erythromycin (E-mycin) DO NOT take with clindamycin or Lincomycin o Extended Macrolides Longer half life Azithromycin (Zithromax) effect of PCNs and clindamycin avoid taking antacids within 2 hours of med Clarithromycin (Biaxin) o the effect of Digoxin, Tegretol, Theophylline, Cyclosporin & Warfarin o NOT administered IM (OUCH!!!) Safety: o LFTs o Urine Output Side Effects: o N/V/D, abdominal cramps Adverse Reactions: o Jaundice/icteric, anaphylaxis, superinfection, hearing loss o Hepatotoxicity erythromycin, azithromycin + other hepatotoxics Nursing Interventions o Obtain C&S o Monitor VS & UO o Monitor Liver Functioning Jaundice

LFT Bilirubin Instruct client to report loose stools Pseudomembranous colitis (C. diff)

Lincosamides Inhibits bacterial protein synthesis Bacteriostatic & Bacteriocidal Drugs: o Clindamycin (Cleocin) Most gram (+) S. aureus & anaerobic organisms Side Effects N/V, rash Adverse Reactions Colitis, anaphylactic shock, stomatitis Glycopeptides Glycopeptide bacteriocidal antibiotic o Vancomycin (Vancocin) Side Effects: Thrombophlebitis, N/V, dizziness, chills fever Adverse Reactions: Ototoxicity, severe hypotension, tachycardia Redman Syndrome (Red Neck Syndrome) o Red blotching of face, neck, chest o Toxic Effect o Not an allergic reaction Stevens-Johnson Syndrome o Epidermis separates from the dermis o Hypersensitivity affecting skin & mucous membranes Risk of nephron and ototoxicity are potentiated with: Furosemide, aminoglycosides, amphotericin B, colistin, cisplatin, cyclosporine Ototoxicity can be masked with Dramamine May inhibit methotrexate excretion = TOXICITY Oral absorbtion of Vancomycin is with cholestyramine & colestipol Monitor: Peak & Trough levels BUN, Cr o Telavancin (Vibativ) Once Daily Select gram (+) bacteria & skin infections Indications of use: o Drug resistant staphylococcus aureus o Cardiac surgical prophylaxis if PCN allergy Ketolides Inhibits protein synthesis bacterial cell death Drugs: o Telithromycin (Ketek) >18 y/o mild to moderate CA-pneumonia Side Effects/ Adverse Reactions: H/A, dizziness, N/V/D, altered taste, liver failure Drug Interactions: Telithromycin (Ketek) levels with o Antilipidemics, itraconazole, ketoconazole, benzodiazepines Telithromycin (Ketek) levels with o Rifampin, phenytoin, carbamazepine, phenobarbitol Increases multiple other drug levels

TETRACYCLINES Short acting o Otetracycline (Sumycin) Intermediate-Acting o Demeclocycline (Declomycin) effect of oral contraceptives absorption of Digoxin TOXICITY Absorption enhanced w/ food Long-acting o Doxycycline hyclate (Vibramycin) PO rapid & complete absorption in newer preparations IV used to treat severe infections Administration: o Antacids, high Calcium, iron drugs CAN PREVENT ABSORBTION OF TETRACYCLINES o Dairy products Tetracycline effect Side Effects: o N/V/D, H/A, photosensitivity o Teratogenic o Tetracycline Teeth Candy Corn Teeth Adverse Reactions: o Superinfections, hepatoxicity, nephrotoxicity (high doses), CNS toxicity, pseudomembranous colitis, intercranial hypertension, blood dyscrasias Labs: o Potassium o Bun o Cr o LFTs GLYCYCLINES Broad spectrum gram (+) & gram (-) Blocks protein synthesis Bacteriostatic Drugs: o Tigecycline (Tygacil) Side Effects & Adverse Reactions: N/V/D, pain, photosensitivity, HTN, hypotension, anemia, leukemia, leukocytosis, thrombocytopenia Hyperglycemia, hypokalemia, BUN, LFTs Concurrent Therapy Effects: Oral contraceptives are less effective Warfarin levels may Indications of Use: o Complicated skin infections, intrabdominal infections o E. coli, S. aureus, Klebsiella pnuemonia AMINOGLYCOSIDES Inhibits bacterial protein synthesis o Gram (-) o Some gram (+) cocci are resistant PCNs or Cephalosporins are used Indications of Use: o PID, MRSA, pseudomonas o Serious infections Drugs NO GI absorption: Primarily given IV & IM o Amikacin (Amikin) o Gentamicin (Garamycin) o Neomycin (Mycifradin) o Tobramycin (Nebcin) Side Effects: o N/V, rash, photosensitivity

Adverse Reactions: o Ototoxicity, nephrotoxicity, liver damage, thrombocytopenia, agranulocytosis Safety: o Peak & Trough o BUN, Serum, AST, ALT, LDH, Cr, Bilirubin o Serum K+, Magnesium o Nephrotoxicity Renal functioning, dose & age o Ototoxicity risk Concurrent ethacrynic acid treatment Nursing Interventions: o Check for hearing loss and balance o Monitor UO Report <600mL/24 hours o Peak & Trough Gentamicin o Monitor for superinfection o Fluid Intake

FLUOROQUINOLONES Broad spectrum bacteriocidal o Interferes with enzyme DNA gyrase o Gram (-) & gram (+) o Bacteriocidal Indications of Use: o UTI, STIs, bones, joints, bronchitis, gastroenteritis, salmonella, pneumonia Drugs: o ciprofloxacin HCl (Cipro) o levofloxacin (Levaquin) o ofloxacin (Floxin) o moxifloxacin (Avelox) Safety: o Food SLOWS absorption rate o levofloxacin drug absorption with: Antacids & Iron (within 4 hours) o Levofloxacin the effect of: Oral hypoglycemic, theophylline, caffeine When taken with NSAIDs, CNS reactions (bradycardia, anxiety) can occur o BUN/Cr & UO Elevated = kidney dysfunction Fluid >2000mL/day Urine pH <6.7 Side Effects: o Dizziness, photosensitivity, N/V/D, abdominal pain Adverse Reactions: o Seizures, cardiac dysrhythmias, superinfection o Stevens-Johnson Syndrome LIPOPEPTIDES Bacteriocidal Drugs: o Daptomycin (Cubicin) Indications: o Complicated gram (+) skin infections, S. aureus septicemia and MRSA infective endocarditis Side Effects: o HTN, hypotension, anemia, tingling Adverse Reactions: o Chest pain, hyper and hypokalemia, hyper and hypoglycemia, bleeding, rhabdomyolysis, pleural effusion Drug Interactions: o Toxicity with tobramycin

Increased bleeding with Warfarin

SULFONAMIDES Bacteriostatic o Inhibit bacterial synthesis of folic acid o Gram (-) o Prevents bacterial growth in the kidneys and bladder Indications of Use: o UTI, ear infections, meningococcal meningitis, newborn eye prophylaxis, STIs Short Acting: o Sulfadiazine (Microsulfon) Intermediate-Acting: o Trimethoprim-sulfamethoxazole (Bactrim, Septra) Topical: o Silver sulfadiazine (Silvadene) CAN BE USED IN CLIENTS WITH PENICILLIN ALLERGY!!! Side Effects/ Adverse Reactions: o Skin rash, itching, photosensitivity, cross-sensitivity, N/V/D o Erythema Multiforme Severe hypersensitivity reaction Macular, vesicular eruptions o Exfoliative Dermatitis Adverse reaction Covers entire body Desquamation, scaling, itching Prolonged Use: o Hemolytic or aplastic anemia, thrombocytopenia, neutropenia, agranulocytosis Nursing Interventions: o Teaching Crystalluria fluid intake Sunglasses, report bruising or bleeding o Assess renal functioning BUN/Cr and UO Bactrim & Septra contraindicated in renal clients o hypoglycemic effect w/ hypoglycemic o anticoagulant effect with Warfarin URINARY TRACT DISORDER DRUGS Upper UTI Pyelonephritis Lower UTI Cystitis, urethritis, or prostatitis Urinalysis and C&S Prior to TX Acute Cystitis o Demographics o Signs & Symptoms Urinary Antiseptics/ Antiinfectives & Antibiotics Drugs: o Nitrofurantoin (Macrodantin) Bacteriostatic & Bacteriocidal (Depends on Dose) Gram (+) & gram (-) Indications of Use Acute and chronic UTI Adverse Reactions: Dyspnea, chest pain, cough, fever, chills Nursing Considerations: Peripheral neuropathy absorption with antacids Accumulates in serum with urinary dysfunction o Methenamine (Hiprex) Bacteriocidal when pH <5.5

Gram (+) & gram (-) Indications of Use chronic UTI Nursing Considerations: Crystaluria with sulfonamides Avoid alkaline foods

Urinary Analgesics Drugs: o Pyridium (Phenazopyridine) Urinary Analgesic Azo dye Relieves pain, burning, frequency, and urgency Indications of Use: Lower UTI Concurrent antibiotic TX Clinitest alters the result Side Effects/ Adverse Reactions: GI disturbances, hemolytic anemia, blood dyscrasias, nephrotoxicity, hepatotoxicity Teaching: Reddish-orange urine from dye May stain contact lenses Report N/V/D Urinary Stimulants Parasympathomimetics o Drugs: Urecholine bladder tone produces contraction that stimulates micturition (urination) Urinary Antispasmodics/Antimuscarinics Relieve urinary tract spasms o Direct action on urinary tract smooth muscles Drugs: o DMSO o Oxybutynin o flavoxate Contraindications: o GI Obstructions o Glaucoma Side Effects: o Dry mouth, HR, dizziness, GI distention, constipation Teaching: o Report retention, severe reaction, blurred vision, palpitations, confusion o Avoid prolonged heat exposure Probenecid & Antibiotics When taken with Aspirin & Amoxicillin or Cloxacillin serum antibacterial levels When administered with Cefazolin or Cefaclor antbiotic excretion is drug accumulation When administered with Ciprofloxacin the effects of Ciprofloxacin are Adverse Effect of Antibacterials Allergy or hypersensitivity reaction o Mild rash, pruritis, hives antihistamine o Severe laryngeal edema, bronchospasms, cardiac arrest epinephrine, bronchodilators, and antihistamine o Usually occurs in the first 20 minutes Superinfection Organ Toxicity o Liver o Kidneys

 Peak & Trough Review Peak o Drawn at drugs peak o Indicates rate of drug absorption Trough o Drawn minutes before the 4th dose (after the 3rd dose is what MDs usually write on order) o Indicates rate of drug elimination Gentamicin o Peak 5-10 o Toxic Peak >12 o Trough <2 o Toxic Trough >2 o Peak occurs 30 minutes after IV administration Liver & Kidney Tests CLcr o Most accurate lab test in determining renal function o Determines how we adjust the dose BUN o Determines renal functioning or dehydration (high levels) Creatinine o Specific indicator of renal functioning LFTs o AST o ALT o Alk Phos Physical Assessment Findings Describe wound, surgical site Monitor for allergic reaction, notify MD, and document finding promptly o Rash, wheeze, fever, etc Kidney/ Liver Damage o Jaundice/icteric o Urine output Superinfection Nursing Process: Assessment: o Allergies o Lab results LFTs, Peaks, Troughs, C&S o Record/ Report UO, VS o Diet o HX o Physical assessment Diagnosis: o Risk for impaired tissue integrity o Risk for ineffective tissue perfusion o Noncompliance with drug regimen o Ineffective protection Planning/ Goals: o Short term: Client will demonstrate meticulous hand washing technique by 1300 Client will demonstrate knowledge of risk factors associated with infection by 1100 Interventions: o Send labs, swabs Before antibiotic administration o Assess for allergic reaction Medical alert bracelet Monitor temperature 1 hr after antipyretic

2nd antipyretic may be added Use cooling measures

Evaluation: o Infection ceased o Adverse reactions: Superinfection o WBC within normal limits o Afebrile o VSS HR RR

Patient Teaching Teaching Plan o Indication of use o Schedule/duration o Food considerations o Interaction w/ herbs & other medications Validation of understanding STI prevention Hand washing Take full course of antibiotic as directed o Finish full Rx o Prevent resistance Report side effects/ adverse reactions o Superinfection Cultural Considerations Alternative practices o Curandero/healer Language barrier o Translator Drug schedule o Alternative methodology Complimentary Alternative Medicine (CAM) Client Preference o Homeopathic vs RX Interactions w/ RX? o Previous experience Teaching o Stress importance of medical regimen Family Involvement o Teach Client with family at bedside