Professional Documents
Culture Documents
• Risk Factors:
– Prolonged or recent hospitalization
– Recent antibiotic use
– Mechanical ventilation
– Long term care facility
– Indwelling lines, tubes, catheter
Highly Resistant Gram (-)
Additional Risk Factors:
• Pseudomonas:
– Immunodeficiency
– Cystic fibrosis
• ESBL:
– Emergency abdominal surgery
• Acinetobacter:
– Warm and humid climate
ESBL
Bacteria
Types of
Acinetobacter
Pseudomonas
3rd + 4th Cephalosporins
+
++
(Ceftazidime & Cefepime)
Extended-Spectrum
+
++
(Piperacillin + Tazobactam)
+
Carbapenems
++
++
-
-
+
Aztreonam
Treatment for
-
+
Aminoglycosides
++
Highly Resistant Gram (-)
Fluoroquinolone
-
-
(Ciprofloxacin and
++
Levofloxacin)
“Anaerobes”
• Bacteria reproduce without the presence of
oxygen
• Found predominantly on GI tract (c-diff
infection), oral and pulmonary cavity (aspiration
PNA)
• Examples:
– Clostridium (difficile, tetanus, and botulism)
– Bacteriodes
– Peptostreptococcus
– Actinomyces
“Anaerobes”
Antibiotics that cause pseudomembranous colitis “c-diff”:
• Clindamycin
• Fluroquinolones
• Beta-lactam drugs
• Other “broad spectrum” antibiotics (tetracycline,
sulfonamide, nitrofurantoin)
MSSA + ++ +
MRSA - - -
Strep ++ + +
Gram (-) - - ++
Anaerobes - ++ ++
Pseudomonas - - ++
Penicillinases (Beta-Lactamases)
• Enzymes that cause penicillin to be inactive
• Bacteria can produce a large variety of these
enzymes specific for penicillin (and other beta-
lactam antibiotics)
Beta-Lactamase Inhibitors
Mechanism of Action:
• Cleave the beta-lactam rings Inhibit bacterial beta-
lactamases
Therapeutic Use:
• Combine with PCN to extend antimicrobial spectrum
• Sulbactam
• Tazobactam
• Clavulanic acid
Resistance:
• 1st generation destroyed by beta-lactamases
• 2nd generation less sensitive to destruction
• 3rd and 4th generations highly resistant
Elimination: Kidneys
Cephalosporins
Antimicrobial Spectrum
Gram (+) ++ ++ ++ ++
MRSA - - - -
Gram (-) + ++ ++ ++
Anaerobes +/- ++ + +
Ceftazidime
Pseudomonas - - only
++
Cephalosporins
First Generations Third Generations
• Cefadroxil • Cefixime
• Cefazolin • Ceftriaxone
• Cephalexin • Ceftazidime
Second Generations Fourth Generations
• Cefaclor • Cefepime
• Cefotetan
• Cefoxitin
Cephalosporins
Adverse Effects:
• Allergic Reactions
– Do not give cephalosporins to patients with a history
of severe reactions to PCN
• Bleeding
– Interference with vitamin K ↓prothrombin
• Thrombophlebitis
– For IV infusion
• Hemolytic Anemia
Cephalosporins
Drug Interactions (negative effects):
• Probenecid delays renal excretion
• ETOH disulfiram effect (N/V, flushing,
tachycardia, SOB)
• Aminoglycosides ↑nephrotoxicity
• Drugs promote bleeding ↑bleeding
• Calcium + Ceftriaxone form fatal
precipitates
A client develops an increased temperature
after surgery. Ceftriaxone (Rocephin) is
prescribed. For which potential effect should the
nurse monitor the client?
a. Dehydration
b. Heart failure
c. Constipation
d. Allergic response
A patient taking an oral cephalosporin
complains of nausea. What should the nurse
have the patient do to decrease the nausea?
a. 0.05% or less
b. 10% to 20%
c. 50% to 60%
d. 90% to 100%
Carbapenems
Mechanism of Action:
• Bind to PBPs weakening of bacterial cell wall
Antimicrobial Spectrum:
• Very broad Gram (+), Gram (-), Pseudomonas
(except for ertapenem)
• Very effective against Anaerobes
• Reserve for serious infections
Elimination: kidneys
Carbapenems
• Imipenem
• Meropenem
• Ertapenem
• Doripenem
Adverse Effects:
• GI effects (N/V/D)
• Superinfections
• Hypersensitivity
Carbapenems
Drugs Interactions (negative effect):
• Valproate reduce blood levels of valproate
cause seizure
Aztreonam
Mechanism of Action:
• Binds to PBP inhibits cell wall synthesis
promote cell lysis and death
Antimicrobial Spectrum:
• Only active against Gram (-) aerobic
• Highly resistant to beta-lactamases
Elimination: kidneys
Adverse Effects:
• Thrombophlebitis
Vancomycin
Mechanism of Action:
• Binds to precursors of cell wall Inhibit cell wall
synthesis bacteria lysis and death
• Does not interact with PBPs
Antimicrobial Spectrum:
• Against Gram (+) bacteria, esp staph and
anaerobes (c-diff)
Absorption: poorly in GI (IV is a preferred route; PO
is reserved for c-diff)
Elimination: kidneys
Vancomycin
Therapeutic Uses:
• MRSA (drug of choice)
• Severe CDI (clostridium difficile infection) PO only
– Use metronidazole for mild to moderate CDI
• Severe staph and strep infections for patients allergic
to PCN and cephalosporins
Adverse Effects:
• GI – C/N/D
• Myopathy
The patient is taking daptomycin for an MRSA
infection. What side effects should the nurse
monitor for in this patient?
a. Severe tachycardia
b. Increased blood pressure
c. Increased blood glucose levels
d. Muscle injury
Drug-Induced Myopathy
• ETOH
• Glucocorticoids Check
• Statins creatine
kinase (CK)
• Colchicine
• Cocaine
• First Generation Antipsychotics (FGAs)
– Neuroleptic malignant syndrome
• Antiretroviral (NRTI)
Inhibit Protein Synthesis
Aminoglycosides Tetracyclines
• Gentamicin • Doxycycline
• Streptomycin • Demeclocycline
• Neomycin • Minocycline
• Amikacin Macrolides
• Azithromycin
• Clarithromycin
• Erythromycin
Aminoglycosides
Mechanism of Action:
• Bind to 30S ribosomal subunit disrupt
bacterial protein synthesis
Antimicrobial Spectrum:
• Only active against Gram (-) bacilli aerobic
(narrow spectrum)
• Doxycycline
• Demeclocycline
• Minocycline
Tetracyclines
Therapeutic Use:
• Infectious Diseases:
– Rickettsial diseases (Rocky Mountain spotted fever,
typhus fever, Q fever)
– Infections caused by Chalmydia trachomatis
– Cholera
– Mycoplasma pneumonia
– Lyme disease
– Anthrax
– Gastric infection with H. pylori
Tetracyclines
Therapeutic Use:
• Acne
• Peptic Ulcer Disease
– H. pylori
• Periodontal Disease
– Doxycycline and minocycline
Tetracyclines
Absorption:
• Orally effective
• Decreased in absorption with:
– Calcium supplements
– Milk products (contain calcium)
– Iron supplements
– Magnesium-containing laxatives
– Most antacids (containing magnesium and/or
aluminum)
* Tetracyclines form chelates with metal ions
Tetracyclines
Elimination:
• Kidneys (tetracycline and demeclocycline –
both are short and intermediate acting)
• Liver (doxycycline and minocycline – both are
long acting)
Tetracyclines
Adverse Effects:
• GI Irritation & Suprainfection C-diff and
Candida
• Yellowish Teeth hypoplasia of the enemal
• Suppress long-bone growth in infants
• Photosensitivity
• Hepatotoxicity (for doxycycline and minocycline)
• Nephrotoxicity (for tetracycline and demeclocycline)
Mnemonic = Tummy, Teeth, Taller, Terrible Vision
Tetracyclines
Drug and Food Interactions:
• Milk products, calcium supplements, iron
supplements, magnesium laxatives, and most
antacids ↓absorption of tetracyclines
• Administer at least 1 hour before or 2 hours
after ingestion of chelating agents
A client with an intractable infection is receiving
tetracycline. Which laboratory blood test result
should the nurse report?
a. Hematocrit: 45%
b. Calcium: 9.0 mg/dL
c. White blood cells (WBC): 10,000 mm3
d. Blood urea nitrogen (BUN): 30 mg/dL
A pregnant client with an infection tells the nurse
that she has taken tetracycline (Tetracyn) for
infections on other occasions and prefers to take it
now. The nurse tells the client that tetracycline is
avoided in the treatment of infections in pregnant
women because it:
a. Tinnitus
b. Diarrhea
c. Dizziness
d. Headache
Clindamycin
Mechanism of Action:
• Binds to 50S ribosomal subunit inhibit protein
synthesis
Antimicrobial Spectrum:
• Broad against Gram (+) and Gram (-)
Therapeutic Uses:
• Alternative to PCN
• Group A strep infection
• Gas gangrene
Elimination: mostly liver
Clindamycin
Adverse Effects:
• Clostridium difficile-associated Diarrhea
(CDAD)
– Can be treated with vanco and metronidazole
• Hepatotoxicity
• Blood dyscrasias
Linezolid (Zyvox)
Mechanism of Action:
• Binds to 50S ribosomal subunit inhibit
protein synthesis
Antimicrobial Spectrum:
• Only active against gram (+)
Elimination: kidneys
Inhibit Folate Synthesis
Antimicrobial Spectrum:
• Sulfonamides and Trimethoprim Broad
spectrum Gram (+), Gram (-), protozoa,
fungi (pneumocystis jiroveci in HIV patients)
Therapeutic Uses:
• UTI (uncomplicated)
• TMP/SMZ Pneumocystis PNA
Inhibit Folate Synthesis
• Sulfonamides
– Sulfamethoxazole
– Sulfisoxazole
– Sulfadiazine
– sulfacetamide
• Trimethoprim
• Trimethoprim/Sulfamethoxazole (TMP/SMZ) -
combo
Inhibit Folate Synthesis
Adverse Effects (Sulfonamides):
• Hypersensitivity Reactions
– Photosensitivity, rash, fever
– Most severe Stevens-Johnson syndrome (widespread
lesions of skin and mucous membrane)
• Nephrotoxicity
• Crystalluria
– Crystalline aggregates in urinary tract renal damage
• Hemolytic Anemia
• Kernicterus
– Deposition of bilirubin in the brain neurotoxic
– Cannot be given to infants < 2y/o or near term pregnancy
Inhibit Folate Synthesis
Adverse Effects (Trimethoprim):
• Pancytopenia – anemia, thrombocytopenia,
neutropenia
• HyperK suppress renal secretion of K
• Fetal malformations
Inhibit Folate Synthesis
Drugs Interactions (Sulfonamides):
• Warfarin intensify bleeding
• Phenytoin increase phenytoin levels
• Sulfonylurea oral hypoglycemic cause
hypoglycemia
• Drugs containing sulfa
– Thiazide and loop diuretics
– sulfonylurea oral hypoglycemics
A 7-year-old child contracts a urinary tract
infection. A sulfonamide preparation is
prescribed. What is the priority nursing
responsibility when the nurse is administering
this drug?
a. Breath sounds
b. Hemoglobin level
c. Consistency of stool
d. White blood cell (WBC) count
Alter Bacterial DNA
Fluoroquinolones (FQ)
• Ciprofloxacin*
• Moxifloxacin
• Levofloxacin*
• Gemifloxacin
• Ofloxacin
• Norfloxacin
Metronidazole
Nitrofurantoin*
Pseudomonas ++ + -
Atypical + ++ ++
Fluoroquinolones
Therapeutic Uses:
• Respiratory Infections (sinusitis, bronchitis,
PNA) except for Cipro*
• UTI and prostatitis
• Complicated skin infections
• Anthrax
Adverse Effects:
• GI – A/N/V/D/C and metallic taste “dysguesia”
• CNS – confusion, dizziness, peripheral neuropathy
• Allergic reactions – urticaria, flushing,
bronchospasm
Metronidazole (Flagyl)
Drug and Food Interactions:
• ETOH and ETOH-containing drugs (cough/cold
syrups)
– disulfiram-like reaction (tachycardia, palpitation, N/V)
• Lithium
– Renal retention of lithium ↑lithium toxicity
• Phenytoin increase phenytoin level
• Warfarin increase warfarin level
• Carbamazepine increase carbamazepine level
A client with gastric ulcer disease asks the nurse
why the health care provider has prescribed
metronidazole (Flagyl). The nurse explains,
"Antibiotics are prescribed to:
Antimicrobial Spectrum:
• Broad Gram (+) and Gram (-)
Therapeutic Use:
• For lower urinary tract infection (uncomplicated)
• NOT for upper UTI (such as pyelonephritis)
Therapeutic Use:
• Active and latent TB
Therapeutic Uses:
• TB
• Leprosy
Therapeutic Uses:
• Active TB combine with rifampin, isoniazid,
and ethambutol
• Latent TB combine with rifampin
Pyrazinamide
Adverse Effects:
• Hepatotoxicity
• Non-gouty polyarthralgias
• Hyperuricemia
– Inhibit excretion of uric acid
Ethambutol
Mechanism of Action:
• Poorly understood – possible suppression of
mycolic acid in the cell wall
Therapeutic Uses:
• TB
Adverse Effects:
• Optic Neuritis
– Red/green color vision, blurred vision
A client with tuberculosis is to begin Rifater
(combination of isoniazid [INH], rifampin [RIF], and
pyrazinamide [PZA]), and streptomycin sulfate
(streptomycin) therapy. The client says, "I've never had
to take so much medication for an infection before."
The nurse should explain:
a. Hot dogs
b. Red wine
c. Sour cream
d. Apple juice
A nurse is reviewing the history and physicals of
several clients from the clinic who are taking
rifampin (Rifadin) for the treatment of
tuberculosis. Which client presents a specific
concern for the nurse?
Ganciclovir
Valganciclovir
Ganciclovir
Mechanism of Action:
• Converted to its active form inside infected cells
suppresses replication of viral DNA
Therapeutic Uses:
• Treat and prevent CMV in immunocompromised
patients (HIV/AIDS pts, chemo-use)
Elimination: Kidneys
Ganciclovir
Adverse Effects:
• Nephrotoxicity
• Granulocytopenia and thrombocytopenia
• Teratogenic
Drugs for Hepatitis
• Hepatitis C
– Interferon Alfa
– Ribavirin (oral)
– Protease Inhibitors
• Hepatitis B
– Interferon Alfa
– Nucleoside Analogs
• Lamivudine
Drugs for Hepatitis C
Traditional Therapy:
• Pegylated* Interferon Alfa (peginterferon alfa) +
Ribavirin
New Standard of Care:
• Adding Protease Inhibitor (boceprevir or telaprevir) to
the traditional therapy
Two types:
• Conventional – short ½ life at least 3x/week
• Long Acting – long ½ life once a week
increase compliance
Drugs for Hepatitis C: Interferon Alfa
Adverse Effects:
• Flu-like symptoms
– Fever, fatigue, myalgia, HA, chills
• Neuropsychiatric Effects
– Depression, suicidal ideation
Drugs for Hepatitis C: Ribavirin
Mechanism of Action: unclear
Therapeutic Uses:
• HCV – cannot use alone, must combine with
interferon
• Respiratory syncytial virus in children
Adverse Effects:
• Hemolytic anemia
• Fetal injury (pregnancy category X)
Drugs for Hepatitis C:
Protease Inhibitors
Protease Inhibitors:
• Boceprevir
• Telaprevir
Adverse Effects:
• Pancytopenia
Drugs Interactions:
• Drugs that Induce and Inhibit P450 many
drugs interactions!
Drugs for Hepatitis B
Interferon Alfa
Nucleoside Analog
• Lamivudine
Therapeutic Uses:
• HBV
• HIV
Drugs for Hepatitis B: Lamivudine
Adverse Effects:
• Lactic acidosis
• Pancreatitis
• Severe hepatomegaly
Drugs for Influenza
Neuraminidase Inhibitors
• oseltamivir
• zanamivir
Therapeutic Uses:
• Treatment and Prevention of Influenza
Drugs for Influenza
Treatment of Influenza:
• Dosing must begin early (no later than 2 days after
symptom onset)
• If treatment is started within 12 hours symptom
duration reduced by 3 days; 24 hours less than 2
days; 36 hours less than 30 hours
Prevention of Influenza:
• Nursing home patients
• Family members of someone with the flu
Drugs for Influenza
Mechanism of Action:
• Inhibit neuraminidase (viral enzyme required
for replication)
Adverse Effects:
• N/V
• Severe hypersensitivity
• Neuropsychiatric effects (younger patients)
– Delirium, abnormal behavior, death
Antiretroviral
• NRTI
• NNRTI
• Protease Inhibitors
• Integrase Inhibitor
• Fusion Inhibitor
Antiretroviral Therapy (ART)
Primary goals of ART:
• increase disease-free survival through suppression of HIV
replication
• improvement in immunologic function
Therapeutic Use:
• Treat HIV infection
– Decrease viral load
– Increase CD4 T-cell counts
– Delay onset of disease symptoms
NRTI
Abacavir
Tenofovir
Zidovudine
Stavudine
Lamivudine
Zalcitabine
Emtricitabine
NRTI
Adverse Effects:
• Lactic Acidosis and Hepatic Steatosis (All NRTIs)
– A/N/V, fatigue, hyperventilation
– Check lactic acid level
• Peripheral Neuropathy (Didanosine and
Stavudine)
• Bone marrow suppression (Zidovudine)
– Severe anemia and neutropenia
• Pancreatitis (Didanosine)
Non-Nucleoside Reverse
Transcriptase Inhibitors (NNRTIs)
Mechanism of Action:
• Binds directly to HIV reverse transcriptase
inhibit the enzyme
Adverse Effects:
• CNS symptoms
– Dizziness, insomnia, drowsiness, vivid dreams,
nightmares, hallucinations, delusions
• Rash
• Hepatotoxicity
• Teratogenic
NNRTIs
Efavirenz recommended first line
Nevirapine
Delavirdine
Etravirine
Protease Inhibitors
Mechanism of Action:
• Bind to HIV protease prevent the enzyme
from cleaving HIV polyproteins HIV remain
non-functional, immature, and non-infectious
Protease Inhibitors
Adverse Effects:
• Hyperglycemia, new onset diabetes
• Lipodystrophy
• Hyperlipidemia
• Increase bleeding in Hemophilia
• Reduced Bone Mineral Density
• Liver damage
Protease Inhibitors
Lopinavir
Ritonavir
Indinavir
Saquinavir
Nelfinavir
Fosamprenavir
Integrase Inhibitor: Raltegravir
Mechanism of Action:
• Prevents insertion of HIV-derived DNA into
DNA of CD4 cells blocks HIV replication
Adverse Effects:
• Myopathy and rhabdomyolysis
A client with acquired immunodeficiency
syndrome (AIDS) is receiving a treatment
protocol that includes a protease inhibitor.
When assessing the client's response to this
drug, which common side effect should the
nurse expect?
a. Diarrhea
b. Hypoglycemia
c. Paresthesias of the extremities
d. Seeing yellow halos around lights
Antifungal
• Drugs for Systemic Mycoses
Amphotericin B
Azoles
• Drugs for Superficial Mycoses
Azoles
Griseofulvin
Nystatin
Allylamines
Terbinafine
Drugs for Systemic Mycoses
Common systemic opportunistic mycoses:
• Candidiasis
• Aspergillosis
• Cryptococcosis
Amphotericin B
Azoles
Antifungal: Amphotericin B
Mechanism of Action:
• Binds to components of the fungal cell
membrane (ergosterol)
Therapeutic Use:
• Most systemic mycoses
Therapeutic Use:
• Target broad spectrum of fungal pathogens
Therapeutic Uses
• Dermatophyte infections (ringworms)
• Not active against Candida
Terbinafine (Lamisil):
• Highly against dermatophytes (ringworm and
onychomycosis), less active against candida
A client is receiving antibiotics and antifungal
medications for the treatment of a recurring
vaginal infection. What should the nurse
encourage the client to do to compensate for
the effect of these medications?
Giardiasis
Giardia lamblia Metronidazole, tinidazole
Toxoplasmosis
Pyrimethamine plus
Toxoplasma gondii
clindamycin
Trichomoniasis
Trichomonas vaginalis Metronidazole, tinidazole
Anti-Ectoparasites
• Pediculosis (head, body, or pubic lice)
– Premethrin 1%
• Adverse Effects: burning, stinging, erythema
• Apply for 10 minutes then wash
• Scabies (mites)
– Premethrin 5%
• Apply for 8 to 14 hours before washing
Clinical Practice: CBC
Clinical Practice: Urinalysis
Clinical Practice: Wound Culture
Clinical Practice: Blood Culture
Clinical Practice: BMP, CMP, LFT,
PT/PTT
BMP PT/
LFT
PTT