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

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

Chain of infection….recall

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

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

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

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

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

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

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

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

Adverse reactions con’t  Hematotoxicity ◦ Chloramphenicol  Causes aplastic anemia  Bone marrow cannot make red blood cells

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

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 ◦ Prototype: Pen G Potassium

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)

Cephalosporin classifications  First generation ◦ Most effective against gram +; 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

Cephalosporins  Nursing considerations ◦ Assess for bleeding disorders-check PT levels ◦ Assess kidney and liver function labs ◦ 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

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

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)

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)

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

 Quinolones/fluoroquinolones ◦ First introduced in 1962 ◦ Currently four generations  Macrolides ◦ Low doses-bacteriostatic ◦ High doses-bacteriocidal

 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)

 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

 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)

 Nursing considerations ◦ Do not use in pregnancy ◦ Assess history of hypersensititivity ◦ Monitor labs (liver and kidney, INR) ◦ Macrolides decrease warfarin metablism and excretion

 Clindamycin (Cleocin) ◦ Grm + and – effectiveness ◦ Use: oral infections ◦ Contraindication: hypersensitivity  Limited use due to association w pseudomenbranous colitis

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

 Vancomycin ( Vancocin)  Imipenim (primaxin)

 Ketolides  glycylcyclines

 Tuberculosis: ◦ Cause: ◦ Incidence: ◦ Treatment: prolonged due to cell wall resistance to penetration by anti infective drugs  Multiple drug concurrently

 Isoniazid (INH) (table 34.10) ◦ Action: ◦ Use: ◦ S/E

 General Action:  Amphoericin B (Fungizone) ◦ Systemic  New class: echinocandins ◦ Used for systemic mycoses ◦ Caspofungin: treats aspergilosis

 Azoles ◦ Fluconazole (Diflucan)  Action/use ◦ Nystatin (Mycostatin)

 Nonnucleoside reverse transcriptase inhibitors (NRTI)  Nucleoside and nucleotide reverse transcriptase inhibitors (NNRTI)

 Protease inhibitors  Fusion inhibitor:

 Assessment

 Infection RT  Risk of transmission of infection RT  Risk for infection RT  Risk for injury RT  Deficient knowledge RT

 To prevent…  To alleviate..  To improve…

 Client teaching