You are on page 1of 85

Anti-infective Drugs

Jan Bazner-Chandler
MSN, CNS, RN, CPNP

Bacteria

Bacteria

Gram-positive bacterium has a thick layer of


peptioglycan.
Gram-negative bacterium has a thin
peptioglycan layer and an outer membrane.

Common Bacterial Pathogens

Gram positive

Staphylococcus aureus
Streptocci
Enterococci

Gram negative

Escherichia coli or E-coli


Klebsiella
Proteus
Pseudomonas

Empiric Therapy

Administration of antibiotics based on the


practitioners judgment of the pathogens
most likely to be causing the infection; it
involves the presumptive treatment of an
infection to avoid treatment delay before
specific cuture information has been
obtained.

Prophylactic Antibiotic
Therapy

Antibiotics taken before anticipated exposure


to an infectious organism in an effort to
prevent the development of infection.

IV antibiotics given prior to surgery

Superinfection

An infection occurring during antimicrobial


treatment for another infection, resulting from
overgrowth of an organism not susceptible to
the antibiotic used.
A secondary infection that occurs due
weakening of the patients immune system by
the first infection.

Examples of Superinfections

Fungal or yeast infection


Diarrhea due to diminished normal flora of
the gastrointestinal tract.

Laboratory Tests

Gram stain microscopic identification of


organism
Culture identifies causative agent and
susceptibility to specific antibiotics
Serology titers or antibodies measured
CBC looking at WBC

Cultures

Throat
Wound
Urine
Sputum
Blood

Clinical Pearl

Always collect culture: urine, sputum, wound


drainage, or blood prior to starting antibiotic
therapy.
If technician is drawing blood make sure it
has been done before starting antibiotics.

Antimicrobials

Drugs used to prevent or treat infection


caused by pathogens

Two Classifications

Bactericidal drugs kill bacteria directly.


Bacteriostatic drugs prevent bacteria from
dividing or inhibits their growth.

Two Types of Bacteria

Aerobic grow and live in presence of


oxygen

Staph & Strep

Anaerobic cannot grow in presence of


oxygen

Deep wounds
Characterized by abscess formation, foul-smelling
pus and tissue destruction

Community-Acquired
Infection

Less severe and easier to treat, although


drug resistant strains are increasing
Remember Staph is everywhere it is normal
flora on skin and in the upper respiratory
tract
MRSA: methicillin-resistant-Staphylococcus
aureus

Nosocomial Infections

More severe and difficult to manage because


they often result from drug-resistant
microorganisms and occur in clients whose
resistance is impaired

Pseudomonas
Proteus

Bacterial Resistance

Bacteria develop the ability to produce


substances which block the action of
antibiotics or change their target or ability to
penetrate the cells.

What causes resistance?

Widespread use of antimicrobial drug


Interrupted or inadequate antimicrobial
treatment of infection
Type of bacteria gram-negative strains
have higher rates of resistance
Re-occurring infections
Condition of the host
Location critical care areas

Opportunistic Host

Compromised immune system

Infants
Geriatric population

Cancer
HIV positive low T-cell count
Burns
Skin breakdown
Client with total knee or hip replacement

Client History / Assessment

Allergies
Previous drug reactions
Baseline renal and liver function
Review culture reports for appropriate
antibacterial drug choice
Patient response to antibiotics therapy

Are they getting better?


Any side effects?

Antibiotics

Sulfonamides
Penicillins
Cephalosporins
Macrolides
Fluoroquinolones
Aminoglycosides
Tetracyclines

Sulfonamides

Action: inhibit the growth of bacteria


(bacteriostatic antibiotic) by inhibiting the
growth of susceptible bacteria by preventing
bacterial synthesis of folic acid.
Usually used in combination drugs.

Trimethoprim / sulfamethoxazole: Trade name


Bactrim, Septra, TMP/SMX

Indications

Broad spectrum: can be used against gram


negative and gram positive organisms
Very useful in treating kidney infections since
they achieve a high concentration in the
kidneys.
Susceptible organisms: Enterobacter, E.Coli,
Klebsiella, Proteus
Problem: organisms becoming more resistant

Specific Use of Sulfa Drugs

HIV patients with pneumocystis carinii


May be given Bactrim or Septra
prophylactically.

Contraindications

Drug allergy to sulfa


Use of thiazide and loop diuretics
Pregnant women
Infants younger than 2 months of age

Adverse Effects

Most common is cutaneous reactions can


occur weeks after therapy started.

Erythema multiforme (Stevens Johnson


Syndrome)
Toxic epidermal necrolysis

Photosensitivity reactions: exposure to


sunlight can result in severe sunburn

B-Lactam Antibiotics

Includes 4 major drug classifications

penicillins
cephalosporins
carbapenes
monobactams

Penicillin

Derived from mold fungus

Penicillin

First generation IM or IV
Newer penicillins have been developed that
increase gastric acid stability of penicillin
Good drug since it enters most bodily fluids:
joint, pleural, and pericardial.
Not effective against intraocular (eye) or
cerebral spinal fluid infection (CSF)

Penicillin

Bactericidal action against sensitive bacteria


Action: binds to bacterial wall, resulting in cell
death

Susceptible Bacteria

Gram-positive organisms

Streptococcus
Enterococcus
Staphylococcus

Adverse Reactions

Most common reaction is GI (diarrhea) when


administered orally.
Urticaria (rash), pruritus (itching), and
angioedema (swelling of the throat)
Severe reaction: Stevens Johns Syndrome
Note: when giving IV or IM observe for to 1
hour after giving for adverse reactions.

Hives

Anaphylaxis

Combination Penicillin / Blactamases

Unasyn
Augmentin
Timentin
Zosyn

Ampicillin Synthetic
Penicillin

Broad spectrum effective against several


gram-positive and gram-negative bacteria
E-coli, proteus, Salmonella, Shigella
Not effective against staphylococci on
gonococci
Bronchitis, sinusitis, and otitis media

Ampicillin

Bactericidal action spectrum is broader


than penicillin
Binds to bacterial wall resulting in cell death

Nursing Implications

Same as penicillin
Ask client about oral contraceptive use drug
may cause transient decrease in
effectiveness
Advise to use additional BC barrier
protection during antibiotic therapy

Amoxicillin

Trade name: Amoxil, Trimox, Wymox


Classification: aminopenicillins
Indications: skin infections, otitis media (ear
infection), sinusitis, respiratory infections.
Inexpensive in generic form but required
frequent dosing (q 8 hours)

Amoxicillin

Oral equivalent of Ampicillin


Readily absorbed and reaches therapeutic
levels rapidly
Drug of choice in prevention of bacterial
endocarditis

Clients with total knee or hip replacement, heart


valve replacement need to take prior to any dental
work, endoscopy exams

Dosing for Amoxicillin

Adults: 250 to 500 mg q8h


Infants and children less than 20 kg:

20 40 mg / kg / day divided into doses q 8 hours

Cephalosporins

Widely used drug derived from fungus


Used against gramnegative bacteria
Widely absorbed and distributed in most
bodily fluids placenta and breast milk

Cephalosporin

First generation Cephalosporin drugs do not


reach therapeutic levels in CSF (cerebral
spinal fluid) but 2nd, and 3rd generation drugs
do especially important in treating
meningitis.

Meningitis

First Generation
Cephalosporins

Bactericidal action binds to bacterial cell


wall, causing cell death

Keflex (PO) still used extensively in treatment of


skin infections
Ancef often ordered preoperatively

Impetigo

First Generation
Cephalosporins

Bactericidal action binds to bacterial cell


wall, causing cell death

Keflex (PO) still used extensively in treatment of


skin infections
Ancef often ordered preoperatively in clients
undergoing orthopedic procedures

Keflex

First generation cephalosporin


Action: binds to bacterial cell wall membrane,
causing cell death
Therapeutic effect: bactericidal action against
susceptible bacteria
Active against many gram-positive cocci
step and staph

Client teaching

May be taken with or without food but food


may minimize the GI irritation
Distribution: may cross placenta or enter
breast milk in low concentrations.
Excreted entirely by the kidneys.

Keflex Dosing

Adults: 250 500 mg q 6 hours


Children: 25 50 mg / kg / day in divided
doses q 6 h

Cefazolin or Ancef

Cefazolin first generation cephalosporin


Well absorbed following IM or IV
administration
Crosses to placenta and breast milk in small
concentrations
Minimal CSF penetration
Excreted by kidneys

Knee or hip replacement

Ancef Dosing

IV
Used for UTI, bone and skin infections,
endocarditis
Not suitable for treatment of meningitis
Perioperative prophylaxis

1 gram within 60 minutes of incision


Post operatively every 8 hours for 24 hours (3 doses)

Second-Generation
Cephalosporins

More active against some gram-negative


organisms and anaerobic organisms than the
first generation drugs.
May be effective in infections resistant to
other antibiotics
Penetration into CSF is poor but adequate to
be used in meningitis
Action: bactericidal binds to cell wall

Third Generation Cephalosporin


Drugs

Similar to the second generation but has


increased activity against gram-negative
pathogens even for drug resistant pathogens.
CSF penetration is better than the first two
generation cephalosporin drugs.

Drug / Drug Allergies

If a client is allergic to penicillin there is a 1 to


18% chance they will be allergic to
cephalosporin drugs.

Carbapenems

Has very broad antibacterial action


Are often used for complicated body cavity
and connective tissue infections in the
hospitalized patient.

imipenem-cilastatin (Primaxin)
meropenen (Merrem): only drug in this class used
in the treatment of bacterial meningitis.

Macrolides

Macrolides first developed in the 1950s with


the drug: erythromycin.

Four main drugs

azithromycin * Zithromax
Clarithromcin * Biaxin
dirithromycin
erythromycin

Macrolides

Two of the new drugs in the macrolide


classification: azithromycin and
clarithromycin have longer duration and
improved resistance to acid degradation in
the stomach.

Dosing is less frequent


GI effects decreased
Better absorption than erythromycin

Macrolides

Action: work by inhibiting protein synthesis in


susceptible bacteria.
Contraindications: drug allergy
Adverse effect: new drugs have lower GI
effects and are used in patients allergic to
penicillin / cephalosporin drugs.

Ketaloids

Only one drug in this drug classification


Generic: telithromycin
Trade: Ketek
Available for oral use only.
Better acid stability and antibacterial
coverage than macrolides.

Tetracyclines

Action: binds to divalent (Ca2 + mg2) and Al3


mettalic ions to form insoluble complexes.
Why do you need to know this?

When given with milk, antacids or iron there is a


reduction in oral absorption.
Contraindicated in children under 8 years of age
because it can result in tooth discoloration.

Tetracyclines

When used? Syphilis and Lyme disease

Antibiotics Used to Treat


Serious Infections

IM or IV administration
Have more toxic side effects
Blood levels may need to be monitored to
determine therapeutic versus toxic levels of
mediation in the blood.

Serious Adverse Effects

Nephrotoxicity: Toxicity to kidneys, often drug


induced and manifesting in compromised
kidney function.
Ototoxicity: Toxicity to the ears, often druginduced and manifested by varying degrees
of hearing loss than is likely to be permanent.
Pseudomembranous colitis: a necrotizing,
inflammatory bowel condition associated with
antibiotic therapy.

Aminoglycosides

Pharmacologic classification: Bactericidal


drugs
Therapeutic classification: anti-infective
Action: inhibits protein synthesis at the level
of the 30s ribosome
Work primarily on dosing due to
concentration dependent killing of bacteria

Concentration Dependent

A property of some antibiotics, especially


aminoglycosides and vancomycin, of
achieving a relatively, high plasma drug
concentration, results in the most effective
bacterial kill.

Blood Plasma Levels

Peak levels: refers to amount of drug present in


blood plasma within

15 to 30 minutes of IV drug administration


30 to 90 minutes of IM drug administration

Trough levels: refers to lowest level of drug


present in the blood plasma.

Since the drugs can cause severe adverse effects the


excretion of the drug needs to be monitored.
Blood drawn just before the next dose given.

Adverse Effects
Aminoglycosides

Nephrotoxicity occurs in 5 to 25% and


ototoxicity (damage to VIII cranial nerve)
occurs in 3 to 14%.

Aminoglycosides

gentamicin (Garamycin)
tobramycin (Nobcin, TOBI)
neomycin (Neo-Fradin)

used to irrigate bowel before major bowel surgery


Topical applied to eye and skin infections

Floroquinolones

Action: destroys bacteria by altering their


DNA.
Two most common drugs:

ciproflxcin (Cipro)
clindamycin (Cleocin)

Used in treatment of chronic infections or


deep (anaerobic) abdominal infections and
MRSA.

Major Adverse Side Effect

Clindamycin or Cleocin can cause


pseudomembranous colitis
Signs and symptoms: abdominal pain and
diarrhea

MRSA Infections

MRSA infection is caused by Staphylococcus


aureus bacteria often called "staph."
MRSA stands for methicillin-resistant
Staphylococcus aureus. It's a strain of staph
that's resistant to the broad-spectrum
antibiotics commonly used to treat it. MRSA
can be fatal.

MRSA

Vancomycin

Action: destroys bacteria by binding to the


bacterial cell wall, producing immediate
inhibition of cell wall synthesis and death.
One of the drugs used in MRSA infections
that are resistant to floroquinolones (cleocin).

Adverse Effect

Red man syndrome has often been


associated with rapid infusion of the first dose
of the drug and was initially attributed to
impurities found in vancomycin preparations.
Even after improvement in vancomycin's
purity, however, reports of the syndrome
persist.
Flushing on upper chest, neck and face
Intervention: slow the IV infusion rate.

Drugs to help with the Flu

Tamiflu and Relenza


Uses: active against influenza virus types A
and B.
Shown to reduce the duration of influenza
infection by a few days.

Anti-viral Drugs

Kill or suppress viruses by either destroying


virons or inhibiting their ability to replicate.
Does not irradicate the virus but helps the
immune system to eliminate the virus.

Herpes Zoster

Herpes simplex virus type 1: cold sore


Herpes simplex virus type 2: genital herpes
Human herpesvirus type 3: chicken pox or
shingles
Human herpesvirus type 4: Espstein Barr
Virus
Human herpesvirus type 5: CMV or
cytomegalovirus

Cold Sore

Herpes Zoster - Shingles

Herpes Drugs

Generic: acyclovir
Trade: Zovirax
Action: interferes with DNA synthesis.
Therapeutic effects: Inhibition of viral
replication, decreased viral shedding and
reduced time for healing of lesions.

acyclovir

Comes in topical, po and IV preparations


Should be started within 24 hours of
outbreak.

You might also like