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ANTIBIOTICSANTIVIRALSAANTIFUNGALS
ANTI-TUBERCULARANTIMALARIALANTIMALARIAL
ANTIHELMINTHICANTIHELMINTHICANTIMYCOBACTERIALANTIMYCOBACTERIAL
ANTIVIRALSANTIVIRALSANTIBIOTICSANTIBIOTICS
COMMONLY KNOWN AS COMMONLY KNOWN AS ANTIMICROBIALSANTIMICROBIALS
Winter 2013 1
DRUGS FOR BUGS ??
WHAT IS AN INFECTION?WHAT IS AN INFECTION?A disease or condition caused by a microorganism that releases toxins or invade body tissues◦Localized infection◦Systemic infection
Winter 2013 2
WHO IS MORE LIKELY TO WHO IS MORE LIKELY TO GET AN INFECTION?GET AN INFECTION?
SKIN NOT INTACT
BLOOD SUPPLY IMPAIRED
NEUTROPENIAMALNUTRITIONSUPPRESSION OF
NORMAL BACTERIAL BALANCE
SUPPRESSION OF THE IMMUNE SYSTEM
DIABETESCHRONIC
ILLNESSADVANCED AGE
Winter 2013 3
Winter 2013 4
Infections: Sites of OriginInfections: Sites of Origin
Community-associated infections◦An infection that is acquired by a person who has not been hospitalized or had a medical procedure (such as dialysis, surgery, catheterization) within the past year
Winter 2013 5
Infections: Sites of Origin Infections: Sites of Origin (cont’d)(cont’d)
Healthcare-associated infections◦Contracted in a hospital or institutional
setting◦Were not present or incubating in the patient
on admission to the facility◦More difficult to treat because causative
microorganisms are often drug resistant and the most virulent
◦One of top ten leading causes of death in the U.S.
◦MRSA most common◦Previously known as nosocomial
Winter 2013 6
Healthcare-Associated Healthcare-Associated Infections: PreventionInfections: Prevention
Hand washingAntisepticsDisinfectants
Winter 2013 7
Healthcare-Associated Healthcare-Associated Infections: Prevention Infections: Prevention (cont’d)(cont’d)Disinfectant
◦Kills organisms◦Used only on nonliving objects
Antiseptic◦Generally only inhibits the growth of microorganisms but does not necessarily kill them
◦Applied exclusively to living tissue
FUNCTIONS OF ANTIBIOTICSFUNCTIONS OF ANTIBIOTICS
Winter 2013 8
IDENTIFICATION OF BACTERIAIDENTIFICATION OF BACTERIA
GRAM TESTINGCULTURE AND SENSITIVITY
TESTINGSEND SPECIMEN FIRST !!!!!
START ANTIBIOTIC BEFORE CULTURE RESULTS ARE KNOWN (EMPIRIC THERAPY)
RX MAY CHANGE WHEN CULTURE IS GROWN
Winter 2013 9
Winter 2013 10
BACTERIAL RESISTANCE
Bacterial resistance◦PENICILLINASE USED BY BACTERIA TO DESTROY PCN
◦BETA-LACTAMASE BREAKS DOWN THE STRUCTURE OF THE ABX INACTIVATING THE DRUG
Winter 2013 11
ANTIMICROBIAL RESISTANCE
UNWISE USE OF ANTIBIOTICS◦ANTIBIOTICS ARE NOT EFFECTIVE
AGAINST VIRAL INFECTIONS
◦WHEN VIRAL SYMPTOMS PERSIST, ABX WILL BE USED FOR A SECONDARY BACTERIAL INFECTION
ANTIBIOTICS MAY BE PRESCRIBED AS PROPHYLACTIC TO ANOTHER TREATMENT OR PROCEDURE
Winter 2013 12
ANTIMICROBIAL RESISTANCE
METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS MRSA◦HAND WASHING AND GLOVING
◦GOAL IS TO AVOID HEALTHCARE ASSOCIATED INFECTIONS
◦“COLONIZED” MEANS HARBORS THE BACTERIA
Winter 2013 13
ANTI-INFECTIVES / ANTIBIOTICS
PROPER DOSE AND DURATION OF THERAPY◦ AVERAGE OF 7 – 10 DAYS OF THERAPY
◦ SPECIFY TIME OF DAY TO TAKE THE DRUGS TO MAINTAIN THERAPEUTIC LEVELS
◦ PATIENT MUST COMPLETE ENTIRE RX
◦ NEVER SAVE FOR USE AT ANOTHER TIME
◦ NEVER SHARE WITH ANOTHER PERSON
Winter 2013 14
ADVERSE REACTIONS TO ABXHYPERSENSITIVITY (allergy)
Requires at least one exposure to the drug
◦Mild – Rash, pruritus, urticaria
◦Severe – Anaphylaxis
Laryngospasms (wheezing)DyspneaDecrease in blood pressure
Winter 2013 15
Winter 2013 16
Winter 2013 17
ADVERSE REACTIONS TO ABX
CROSS-SENSITIVITY REACTIONS◦If allergic to one antibiotic, allergic to antibiotics from same family
◦EXAMPLE – ALLERGY TO PCN, ALSO MAY BE ALLERGIC TO CEPHALOSPORIN
Winter 2013 18
STEVENS-JOHNSON SYNDROMESTEVENS-JOHNSON SYNDROME
◦Severe (can be fatal) hypersensitivity reaction caused by reaction to a medication
◦Typically involves the skin and mucous membranes developing severe inflammation progressing to necrosis of the tissues. Can also progress to the lining of internal organs.
◦TABER’S – TOXIC EPIDERMAL NECROLYSIS
Winter 2013 19
Winter 2013 20
Winter 2013 21
Winter 2013 22
SUPERINFECTION
◦A secondary infection that occurs during antibiotic therapy in which normal flora are destroyed
Winter 2013 23
SuperinfectionLOCATION OF INFECTION
◦GROIN◦AXILLA◦MOUTH◦UNDER BREAST TISSUE◦ANY WARM MOIST AREA
OFFENDING ORGANISM◦YEAST◦BACTERIA
Winter 2013 24
Candida Yeast / Thrush
Winter 2013 25
NURSING RESPONSIBILITIESPATIENT’S RESPONSE TO THERAPY
◦ EVALUATE TEMPERATURE, APPETITE AND GENERAL LEVEL OF WELLNESS
FLUID INTAKE ◦ DRUGS ARE NEPHROTOXIC◦ ADVISE PATIENT TO INCREASE PO INTAKE◦ FULL GLASS OF WATER WITH MED◦ WATER WILL DECREASE GI SYMPTOMS
OTHER MEDS◦ LOOK FOR CONTRAINDICATED MEDS◦ LOOK FOR HERBAL INTERACTIONS
Winter 2013 26
CHARACTERISTICS OF ANTIBACTERIALS
BROAD SPECTRUM
NARROW SPECTRUM
MECHANISM OF ACTION
Winter 2013 27
BROAD SPECTRUM BROAD SPECTRUM ANTIBIOTICANTIBIOTIC
AN ANTIBIOTIC THAT IS EFFECTIVE AGAINST BOTH GRAM-NEGATIVE AND GRAM-POSITIVE BACTERIAL SPECIES
BROAD-SPECTRUM AGENTS INCLUDE ◦CARBAPENEMS ◦EXTENDED-SPECTRUM CEPHALOSPORINS◦BETA-LACTAM/BETA-LACTAMASE
INHIBITOR COMBINATIONS◦FLUOROQUINOLONES
Winter 2013 28
NARROW SPECTRUM NARROW SPECTRUM ANTIBIOTICANTIBIOTIC
AN ANTIBIOTIC EFFECTIVE AGAINST A LIMITED NUMBER OF MICROORGANISMS.
EXAMPLES OF NARROW-SPECTRUM AGENTS INCLUDE
PENICILLIN G MACROLIDES NITROFURANTOIN METRONIDAZOLE AZTREONAM NALIDIXIC ACID
Winter 2013 29
MECHANISMS OF ACTIONMECHANISMS OF ACTIONInhibition of bacterial cell wall
synthesisInhibition of protein synthesisDisruption of cell membranesInhibits cell reproductionInhibits cell metabolism
Winter 2013 30
Winter 2013 31
Antibiotics: SulfonamidesAntibiotics: SulfonamidesOne of the first groups of antibiotics
◦Sulfadiazine◦Sulfamethoxazole◦Sulfisoxazole
Often combined with another antibiotic◦Sulfamethoxazole combined with
trimethoprim (a nonsulfonamide antibiotic), known as Bactrim, Septra, or co-trimoxazole (SMX-TMP)
◦This combination is used commonly
Winter 2013 32
Sulfonamides: Sulfonamides: Mechanism of ActionMechanism of Action
Bacteriostatic actionPrevent synthesis of folic
acid required for synthesis of purines and nucleic acid
Do not affect human cells or certain bacteria
Only affect organisms that synthesize their own folic acid
Winter 2013 33
Sulfonamides: IndicationsSulfonamides: Indications
Effective against both gram-positive and
gram-negative bacteria Treatment of UTIs caused by susceptible
strains of:◦Enterobacter , Escherichia coli, Klebsiella ,
Proteus mirabilis, Proteus vulgaris, Staphylococcus aureus
Winter 2013 34
Sulfonamides: Indications Sulfonamides: Indications (cont’d)(cont’d)
Urinary tract infectionsUpper respiratory tract infections
Winter 2013 35
Sulfonamides: Sulfonamides: Adverse EffectsAdverse Effects
Body System Adverse EffectsBlood Hemolytic and aplastic
anemia, agranulocytosis, thrombocytopenia
Integumentary Photosensitivity, exfoliative dermatitis, Stevens-Johnson syndrome, epidermal necrolysis
Winter 2013 36
Sulfonamides: Sulfonamides: Adverse Effects (cont’d)Adverse Effects (cont’d)
Body System Adverse EffectsGI Nausea, vomiting,
diarrhea, pancreatitisOther Convulsions,
crystalluria,toxic nephrosis,
headache, peripheral neuritis, urticaria
http://www.youtube.com/watch?v=ifQMm2xuyqc&playnext=1&list=PL27024F7449C9E999&feature=results_main
Winter 2013 37
Beta-Lactam Antibiotics AntibioticsPenicillinsCephalosporinsCarbapenemsMonobactams
Winter 2013 38
Winter 2013 39
Penicillins Penicillins First introduced in the 1940sBactericidal: inhibit cell wall
synthesisKill a wide variety of bacteriaBacteria produce enzymes
capable of destroying penicillins◦These enzymes are known as beta-
lactamases◦As a result, the medication is not
effective
Winter 2013 40
Penicillins
Natural penicillinsPenicillinase-resistant penicillins
AminopenicillinsExtended-spectrum penicillins
Winter 2013 41
Penicillins (cont’d) (cont’d)
Natural penicillins◦penicillin G, penicillin V potassium
Penicillinase-resistant drugs◦cloxacillin, dicloxacillin, nafcillin, oxacillin
Winter 2013 42
Penicillins (cont’d) (cont’d)
Aminopenicillins◦amoxicillin, ampicillin
Extended-spectrum drugs◦piperacillin, ticarcillin, carbenicillin
◦Usually used with other drugs; rarely used alone
Winter 2013 43
Penicillins (cont’d) (cont’d)
Chemicals have been developed to inhibit these enzymes:◦Clavulanic acid◦Tazobactam◦Sulbactam
These chemicals bind with beta-lactamase and prevent the enzyme from breaking down the penicillin, thus making the drug more effective
Winter 2013 44
Penicillins (Penicillins (cont’d))
Penicillin–beta-lactamase inhibitor combination drugs◦ Ampicillin + sulbactam = Unasyn
◦ Amoxicillin + clavulanic acid = Augmentin
◦ Ticarcillin + clavulanic acid = Timentin
◦ Piperacillin + tazobactam = Zosyn
Winter 2013 45
Penicillins: Penicillins: Indications
Prevention and treatment of infections caused by susceptible bacteria, such as:◦Gram-positive bacteria◦Streptococcus, Enterococcus, Staphylococcus
Winter 2013 46
Penicillins: Adverse Penicillins: Adverse Effects
Allergic reactions occur in 0.7% to 4% of cases ◦Urticaria, pruritus, angioedema
Those allergic to penicillins have a fourfold to sixfold increased risk of allergy to other beta-lactam antibiotics
Cross-sensitivity between penicillins and cephalosporins is between 1% and 4%
Winter 2013 47
Penicillins: Penicillins: Adverse Effects (cont’d)Effects (cont’d)
Common adverse effects◦Nausea, vomiting, diarrhea,
abdominal painOther adverse effects are
less common
Winter 2013 48
Penicillins: Interactions
MANY interactions!◦NSAIDs◦Oral contraceptives –
Decreases effectiveness◦Warfarin – Enhanced
anticoagulant effect r/t decrease in intestinal flora producing vitamin K
◦Others
MRSAMRSAMETHICILLIN RESISTANT
STAPHYLOCOCCUS AUREUS◦Hand washing and gloving
◦Goal is to avoid healthcare associated infections
◦“Colonized” means harbors the bacterial infection
Winter 2013 49
NURSING CONSIDERATIONSNURSING CONSIDERATIONSFOR PENICILLINFOR PENICILLIN
◦Take with a full glass of water
◦Do not skip doses
◦Take all of the medication as prescribed
◦Notify MD of adverse reactions
Winter 2013 50
Winter 2013 51
Winter 2013 52
Cephalosporins
First generationSecond generationThird generationFourth generationFifth generation (not yet
marketed)
Winter 2013 53
Cephalosporins (cont’d)Cephalosporins (cont’d)
Semisynthetic derivatives Structurally and
pharmacologically related to penicillins
Bactericidal actionBroad spectrumDivided into groups according to
their antimicrobial activity
Winter 2013 54
Cephalosporins: Cephalosporins: First First Generation
Good gram-positive coveragePoor gram-negative coverageParenteral and PO formsExamples
◦ cefadroxil◦ cephradine◦ cefazolin◦ cephalexin
Winter 2013 55
Cephalosporins: Cephalosporins: First Generation (cont’d)First Generation (cont’d)
Used for surgical prophylaxis, and for susceptible staphylococcal infections◦cefazolin (Ancef and Kefzol): IV or IM◦cephalexin (Keflex): PO
Winter 2013 56
Cephalosporins: : Second GenerationSecond Generation
Good gram-positive coverage Better gram-negative coverage
than first generation Examples:
cefaclorcefprozilcefoxitincefuroxime loracarbefcefotetan
Winter 2013 57
Cephalosporins: : Second Generation Second Generation
(cont’d)(cont’d)cefoxitin (Mefoxin): IV and IM
◦Used prophylactically for abdominal or colorectal surgeries
◦Also kills anaerobescefuroxime
◦Zinacef is parenteral form; Ceftin is PO◦Surgical prophylaxis◦Does not kill anaerobes
Winter 2013 58
Cephalosporins: Third Generation
Most potent group against gram-negative bacteria Less active against gram-positive bacteria Examples◦ceftibuten◦cefotaxime◦ceftazidime◦cefdinir◦ceftizoxime◦ceftriaxone◦ceftazidime
Winter 2013 59
Cephalosporins: Cephalosporins: Third Generation (cont’d)Third Generation (cont’d)
ceftriaxone (Rocephin)◦IV and IM, long half-life, once-a-day dosing
◦Elimination is primarily hepatic◦Easily passes meninges and diffused into CSF to treat CNS infections
Winter 2013 60
Cephalosporins: Third Generation (cont’d)ceftazidime (Ceptaz)
◦IV and IM forms◦Excellent gram-negative
coverage◦Used for difficult-to-treat
organisms such as Pseudomonas ◦Eliminated by renal instead of
biliary route◦Excellent spectrum of coverage◦Resistance is limiting usefulness
Winter 2013 61
Cephalosporins: Cephalosporins: Fourth Generation Generation
Broader spectrum of antibacterial activity than third generation, especially against gram-positive bacteria
Uncomplicated and complicated UTI◦cefepime (Maxipime)
Winter 2013 62
Cephalosporins: : Fifth GenerationFifth Generation
Ceftobipriole (not available)Broader spectrum of antibacterial
activityEffective against a wide variety of
organisms◦MRSA◦Pseudomonas
Winter 2013 63
Cephalosporins: : Adverse EffectsAdverse Effects
Similar to penicillins◦Mild diarrhea, abdominal
cramps, rash, pruritus, redness, edema
Potential cross-sensitivity with penicillins if allergies exist
Winter 2013 64
CarbapenemsVery broad-spectrum antibacterial
actionReserved for complicated body
cavity and connective tissue infections
May cause drug-induced seizure activity◦This risk can be reduced with proper
dosageAll given parenterally
Winter 2013 65
Carbapenemsimipenem/cilastatin (Primaxin)
◦Used for treatment of bone, joint, skin, and soft-tissue infections; many other uses
◦Cilastatin inhibits an enzyme that breaks down imipenem
meropenem (Merrem)ertapenem (Invanz)doripenem (Doribax)
MonobactamsMonobactams
Aztreonem (Azactam) Only drug in this catagory
Beta-lactam antibioticGram negative bacteria
◦Inhibits cell wall synthesisCommon adverse effects
Winter 2013 66
Winter 2013 67
Macrolides
erythromycin (E-mycin, E.E.S, others)
azithromycin (Zithromax)◦“Z-Pack” 3 – 5 day dose pack
clarithromycin (Biaxin)dirithromycin
http://www.youtube.com/watch?v=2g-2oLb0IQw&feature=related
Winter 2013 68
Macrolides::Mechanism of ActionMechanism of Action
Prevent protein synthesis within bacterial cells
Considered bacteriostaticBacteria will eventually dieIn high enough concentrations,
may also be bactericidal
Winter 2013 69
Macrolides: Macrolides: Indications Strep infections
◦Streptococcus pyogenes
(group A beta-hemolytic streptococci) Mild to moderate URI and LRI
◦Haemophilus influenzae Spirochetal infections
◦Syphilis and Lyme disease Gonorrhea, Chlamydia, Mycoplasma
Winter 2013 70
Macrolides: Macrolides: Indications (cont’d)(cont’d)azithromycin and clarithromycin
◦Recently approved for mycobacterium avium-
intracellular complex infection (opportunistic
infection associated with HIV/AIDS)clarithromycin
◦Recently approved for use in combination with omeprazole for treatment of active ulcer disease associated with Helicobacter pylori infection
Macrolides: Macrolides: Indications (cont’d)(cont’d)Fidaxomicin (Dificid)
◦Treatment of Clostridium difficile-associated diarrhea in adults ≥18 years of age.
◦Following oral administration, only minimal systemic absorption occurs; remains mainly confined to and acts locally in the GI tract.
Winter 2013 71
Winter 2013 72
Macrolides: Adverse : Adverse EffectsEffects
GI effects, primarily with erythromycin◦Nausea, vomiting, diarrhea,
hepatotoxicity, flatulence, jaundice, anorexia
◦Newer drugs, azithromycin and clarithromycin: fewer GI adverse effects, longer duration of action, better efficacy, better tissue penetration
Winter 2013 73
Ketolide
telithromycin (Ketek)◦Only drug in this class◦Better antibacterial coverage than
macrolides◦Active against gram-positive bacteria,
including multi–drug-resistant strains of S. pneumoniae
◦Associated with severe liver disease◦Use is limited
Winter 2013 74
Tetracyclines
demeclocycline (Declomycin)
oxytetracyclinetetracyclinedoxycycline (Doryx,
Vibramycin)minocyclinetigecycline (Tygacil)
Winter 2013 75
Tetracyclines (cont’d) (cont’d)
Natural and semisyntheticObtained from cultures of
StreptomycesBacteriostatic—inhibit bacterial
growthInhibit protein synthesisStop many essential functions
of the bacteria
Winter 2013 76
Tetracyclines: Tetracyclines: Indications
Broad spectrum◦Gram-negative and gram-positive
organisms, protozoa, Mycoplasma, Rickettsia, Chlamydia, syphilis, Lyme disease, acne, others
Demeclocycline is also used to treat SIADH by inhibiting the action of ADH
Winter 2013 77
Tetracyclines (cont’d)Tetracyclines (cont’d)
Bind (chelate) to Ca2+ and Mg2+ and Al3+ ions to form insoluble complexes
Thus, dairy products, antacids, and iron salts reduce oral absorption of tetracyclines
Should not be used in children under age 8 or in pregnant/lactating women because tooth discoloration will occur if the drug binds to the calcium in the teeth
Winter 2013 78
Tetracyclines: Adverse : Adverse EffectsEffects
Strong affinity for calcium ◦Discoloration of permanent teeth and tooth enamel in fetuses and children, or nursing infants if taken by the mother
◦May retard fetal skeletal development if taken during pregnancy
◦ http://www.youtube.com/watch?v=AMAqU7MJ_sc
Winter 2013 79
Tetracyclines: Adverse : Adverse Effects (cont’d)Effects (cont’d)
Alteration in intestinal flora may result in:◦Superinfection (overgrowth of
nonsusceptible organisms such as Candida)
◦Diarrhea◦Pseudomembranous colitis
Winter 2013 80
Tetracyclines: Tetracyclines: Adverse Effects (cont’d)Effects (cont’d)
May also cause:◦Vaginal candidiasis◦Gastric upset◦Enterocolitis◦Maculopapular rash◦Other effects
Winter 2013 81
Antibiotic Therapy: Antibiotic Therapy: ToxicitiesToxicities Ototoxicity
◦ Temporary or permanent hearing loss, balance problems
Nephrotoxicity◦ Varying degrees of reduced renal function◦ Rising serum creatinine may indicate
reduced creatinine clearanceMonitor trough levels every 5 to 7 days while on therapy or as orderedMonitor serum creatinine levels at least every 3 days as an index of renal function
82Winter 2013
Aminoglycosides
gentamicin (Garamycin)neomycin (Neo-fradin)tobramycin (Nebcin)amikacin (Amikin)kanamycinstreptomycin
83Winter 2013
Aminoglycosides (cont’d) (cont’d)Natural and semisyntheticProduced from StreptomycesPoor oral absorption; no PO formsVery potent antibiotics with
serious toxicitiesBactericidal; prevent protein
synthesisKill mostly gram-negative
bacteria; some gram-positive also
84Winter 2013
Aminoglycosides: : IndicationsIndications
Used to kill gram-negative bacteria such as Pseudomonas, E. coli, Proteus, Klebsiella, Serratia
Often used in combination with other antibiotics for synergistic effects
Used for certain gram-positive infections that are resistant to other antibiotics
85Winter 2013
Aminoglycosides: Aminoglycosides: Indications (cont’d)Indications (cont’d)
Aminoglycosides are poorly absorbed through the GI tract, and given parenterally
Exception: neomycin◦Given orally to decontaminate
the GI tract before surgical procedures
◦Also used as an enema for this purpose
86Winter 2013
Aminoglycosides: Aminoglycosides: Adverse Adverse Effects
Cause serious toxicities◦Nephrotoxicity (renal damage)◦Ototoxicity (auditory impairment
and vestibular impairment [eighth cranial nerve])
Must monitor drug levels to prevent toxicities
87Winter 2013
Winter 2013 88
Aminoglycosides: Aminoglycosides: Adverse Effects (cont’d) Effects (cont’d)Ototoxicity and nephrotoxicity are
the most significant◦Headache◦Paresthesia◦Fever◦Superinfections◦Vertigo◦Skin rash◦Dizziness
89Winter 2013
Quinolones
ciprofloxacin (Cipro)norfloxacin (Noroxin)levofloxacin (Levaquin)moxifloxacin (Avelox)
90Winter 2013
Quinolones (cont’d)(cont’d)
Also called “fluoroquinolones”Excellent oral absorptionAbsorption reduced by
antacidsEffective against gram-
negative organisms and some gram-positive organisms
91Winter 2013
Quinolones: Quinolones: Mechanism of ActionMechanism of Action
BactericidalAlter DNA of bacteria,
causing deathDo not affect human DNA
92Winter 2013
Quinolones: IndicationsQuinolones: Indications
Gram-negative bacteria such as pseudomonas
Respiratory infectionsBone and joint infectionsGI infectionsSkin infectionsSexually transmitted diseasesAnthrax
93Winter 2013
Fluoroquinolones: Fluoroquinolones: Adverse EffectsAdverse Effects
Body System Adverse EffectsCNS Headache, dizziness,
fatigue, depression, restlessness, insomnia
GI Nausea, vomiting, diarrhea, constipation, thrush, increased liver function studies, others
Cardiac Prolonged QT interval
94Winter 2013
Fluoroquinolones: Fluoroquinolones: Adverse Effects (Adverse Effects (cont’d))
Body System Adverse EffectsIntegumentary Rash, pruritus,
urticaria, flushing, photosensitivity (with lomefloxacin)
Other Fever, chills, blurred vision, tinnitus
Black box warning: increased risk of tendonitis and tendon rupture
95Winter 2013
Other Other Antibioticsclindamycin (Cleocin)linezolid (Zyvox)metronidazole (Flagyl)nitrofurantoin (Macrodantin)quinupristin and Dalfopristin
(Synercid)daptomycin (Cubicin)vancomycin (Vancocin)colistimethate (Coly-mycin)
96Winter 2013
Other Antibiotics (cont’d) Antibiotics (cont’d)
clindamycin (Cleocin)◦Used for chronic bone infections, GU
infections, intra-abdominal infections, other serious infections
◦May cause pseudomembranous colitis
97Winter 2013
Other Other Antibiotics (cont’d) (cont’d)linezolid (Zyvox)
◦New class: oxazolidinones◦Used to treat vancomycin-resistant
Enterococcus faecium (VREF, VRE), hospital-acquired skin and skin structure infections, including those with MRSA
◦May cause hypotension, serotonin syndrome if taken with SSRIs, and reactions if taken with tyramine-containing foods
98Winter 2013
Other Antibiotics (cont’d) Antibiotics (cont’d)metronidazole (Flagyl)
◦Used for anaerobic organisms◦Intra-abdominal and gynecologic
infections◦Protozoal infections◦Several drug interactions
99Winter 2013
Other Antibiotics (cont’d) Antibiotics (cont’d)nitrofurantoin (Macrodantin)
◦Primarily used for UTIs (E. coli, S. aureus, Klebsiella , Enterobacter)
◦Use carefully if renal function is impaired
◦Drug concentrates in the urine◦May cause fatal hepatotoxicity◦Usually well-tolerated if patient is
kept well-hydrated
100
Winter 2013
Other Antibiotics (cont’d) Antibiotics (cont’d)quinupristin and dalfopristin
(Synercid)◦30:70 combination, work
synergistically◦Used for bacteremia and infections
caused by vancomycin-resistant Enterococcus (VRE) and other complicated skin infections
◦May cause arthralgias, myalgias
101
Winter 2013
Other Other Antibiotics (cont’d) (cont’d)daptomycin (Cubicin)
◦New class: lipopeptide◦Used to treat complicated skin and
soft-tissue infections
102
Winter 2013
Other Antibiotics (cont’d) Antibiotics (cont’d)vancomycin (Vancocin)
◦Natural, bactericidal antibiotic◦Destroys cell wall◦Treatment of choice for MRSA and other
gram-positive infections◦Must monitor blood levels to ensure
therapeutic levels and prevent toxicity◦May cause ototoxicity and nephrotoxicity◦Should be infused over 60 minutes◦Rapid infusions may cause hypotension
103
Winter 2013
Other Antibiotics (cont’d) Antibiotics (cont’d)vancomycin (Vancocin) (cont’d)
◦Monitor IV site closely◦Red man syndrome may occur
Flushing/itching of head, neck, face, upper trunk
Antihistamine may be ordered to reduce these effects
◦Ensure adequate hydration (2 L fluids/24 hr) if not contraindicated to prevent nephrotoxicity
◦Monitor trough levels carefully
104
Winter 2013
Nursing Implications Nursing Implications
It is ESSENTIAL to obtain cultures from appropriate sites BEFORE beginning antibiotic therapy
Instruct patients to take antibiotics exactly as prescribed and for the length of time prescribed; they should not stop taking the medication early when they feel better
105
Winter 2013
Nursing Nursing Implications (cont’d)(cont’d)
Aminoglycosides◦Monitor peak and trough blood levels of these drugs to prevent nephrotoxicity and ototoxicity
◦Symptoms of ototoxicity include dizziness, tinnitus, and hearing loss
◦Symptoms of nephrotoxicity include urinary casts, proteinuria, and increased BUN and serum creatinine levels
106
Winter 2013
ANTIVIRAL MEDICATIONS
Winter 2013 107
Understanding Viruses VirusesViral replication
◦A virus cannot replicate on its own
◦It must attach to and enter a host cell
◦It then uses the host cell’s energy to synthesize protein, DNA, and RNA
108
Winter 2013
Understanding Viruses Viruses (cont’d)(cont’d)
Viruses are difficult to kill because they live inside the cells◦ Any drug that kills a virus may also kill cells
109
Winter 2013
Viral Viral IllnessesMost viral illnesses are
bothersome, but survivableEffective vaccines have
prevented some illnessesEffective drug therapy is
available for a small number of viral infections
110
Winter 2013
Antiviral Drugs DrugsAntiviral drugs kill or suppress
the virus by destroying virions or inhibiting ability to replicate viruses controlled by current antiviral therapy
111
Winter 2013
Antiviral Drugs (cont’d) Drugs (cont’d)Viruses controlled by current
antiviral therapyCytomegalovirus (CMV)Hepatitis virusesHerpes virusesHuman immunodeficiency virus
(HIV)Influenza viruses (the “flu”)Respiratory syncytial virus (RSV)
112
Winter 2013
Antiviral Drugs (cont’d) Drugs (cont’d)Key characteristics of antiviral drugsAble to enter the cells infected
with virusInterfere with viral nucleic acid
synthesis and/or regulationSome drugs interfere with ability of
virus to bind to cells
Some drugs stimulate the body’s immune system
113
Winter 2013
Antiviral Drugs (cont’d) Drugs (cont’d)Opportunistic infectionsOccur in immunocompromised
patientsWould not normally harm an
immunocompetent personRequire long-term prophylaxis
and antiinfective drug therapy
Can be other viruses, fungi, bacteria, or protozoa
114
Winter 2013
Antiviral Drugs (cont’d) Drugs (cont’d)Antiviral drugs
◦Used to treat infections caused by viruses other than HIV
Antiretroviral drugs◦Used to treat infections caused by
HIV, the virus that causes AIDS
115
Winter 2013
Virus Infections InfectionsHerpes-simplex viruses
◦HSV-1 (oral herpes)◦HSV-2 (genital herpes)
Human herpesvirus/VZV◦Chickenpox and shingles (HHV-3 or VZV)
Shingles http://www.youtube.com/watch?v=MEvyptIJsuE
◦Epstein-Barr (HHV-4)◦Cytomegalovirus (HHV-5)◦Kaposi’s sarcoma (HHV-8)
116
Winter 2013
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Antiviral Drugs (non-HIV) Drugs (non-HIV)Mechanism of action
◦Inhibit viral replicationUsed to treat non-HIV viral
infections◦Influenza viruses◦HSV, VZV◦CMV◦Hepatitis A, B, C (HAV, HBV, HCV)
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Winter 2013
Antiviral Drugs (non-HIV) Drugs (non-HIV) (cont’d) (cont’d)
Adverse effects◦Vary with each drug◦Healthy cells are often killed also, resulting in serious toxicities
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Winter 2013
Antiviral Drugs (non-HIV) Drugs (non-HIV) (cont’d)(cont’d)
amantadine (Symmetrel) ◦ Narrow antiviral spectrum; active
only against influenza A◦ 2008 CDC guidelines do not
recommend use for treatment or prevention of flu
◦ CNS effects: insomnia, nervousness, lightheadedness
◦ GI effects: anorexia, nausea, others
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Winter 2013
Antiviral Drugs (non-HIV) Drugs (non-HIV) (cont’d)(cont’d)
rimantadine (Flumadine) ◦ Same spectrum of activity,
mechanism of action, and indications as amantadine
◦ Fewer CNS adverse effects◦ Causes GI upset
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Winter 2013
Antiviral Drugs (non-HIV) Drugs (non-HIV) (cont’d) (cont’d)
acyclovir (Zovirax) ◦ Synthetic nucleoside analog◦ Used to suppress replication of:
HSV-1, HSV-2, VZV
◦ Drug of choice for treatment of initial and recurrent episodes of these infections
◦ Oral, topical, parenteral forms
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Winter 2013
Antiviral Drugs (non-HIV) Drugs (non-HIV) (cont’d)(cont’d)
ganciclovir (Cytovene)◦ Synthetic nucleoside analog◦ Used to treat infection with
cytomegalovirus (CMV)◦ Oral, parenteral forms◦ CMV retinitis
Ophthalmic form surgically implanted Ocular injection (fomivirsen)
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Winter 2013
Antiviral Drugs (non-HIV): Drugs (non-HIV): Dose-Limiting ToxicitiesDose-Limiting Toxicities
ganciclovir ◦ Bone marrow toxicity
foscarnet and cidofovir◦ Renal toxicity
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Winter 2013
Antiviral Drugs (non-HIV): Antiviral Drugs (non-HIV): Neuraminidase Neuraminidase Inhibitors
oseltamivir (Tamiflu) and zanamivir (Relenza)◦ Active against influenza types A and B◦ Reduce duration of illness◦ Oseltamivir: causes nausea and vomiting◦ Zanamivir: causes diarrhea, nausea,
sinusitis◦ Treatment should begin within 2 days of
influenza symptom onset
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Winter 2013
Antiviral Antiviral Drugs (non-HIV): (non-HIV): RibavirinRibavirin
Synthetic nucleoside analogGiven orally, or oral or nasal
inhalationInhalation form (Virazole) used
for hospitalized infants with RSV infections
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Winter 2013
HIV and AIDSHIV and AIDSHuman immunodeficiency virus
(HIV) infection and acquired immune deficiency syndrome (AIDS)◦ELISA (enzyme-linked immunosorbent
assay) Detects HIV exposure based on presence of
human antibodies to the virus in the blood
◦Retrovirus◦Transmitted by sexual activity,
intravenous drug use, perinatally from mother to child
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Winter 2013
Four Stages of HIV Four Stages of HIV Infection*Infection*
Stage 1: asymptomatic infectionStage 2: early, general symptoms of
diseaseStage 3: moderate symptomsStage 4: severe symptoms, often
leading to death
*WHO model
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Winter 2013
Opportunistic Infections Infections
Protozoal◦Toxoplasmosis of the brain, others
Fungal◦Candidiasis of the lungs,
esophagus, trachea◦Pneumocystis jirovecii pneumonia,
othersViral
◦CMV disease, HSV infection, others
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Winter 2013
Opportunistic Infections Infections (cont’d)(cont’d)
Bacterial◦Various mycobacterial infections◦Extrapulmonary TB
Opportunistic neoplasias◦Kaposi’s sarcoma, others
HIV wasting syndrome◦Major weight loss, chronic diarrhea,
chronic fever
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Winter 2013
Antiretroviral Drugs Drugs
HAARTHighly active antiretroviral
therapyIncludes at least three
medications◦“Cocktails”
These medications work in different ways to reduce the viral load
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Winter 2013
Antiretroviral Drugs Drugs (cont’d)(cont’d)
Reverse transcriptase inhibitors (RTIs)◦ Block activity of the enzyme reverse transcriptase,
preventing production of new viral DNAProtease inhibitors (PIs)
◦ Inhibit the protease retroviral enzyme, preventing viral replication
Fusion inhibitors◦ Inhibit viral fusion, preventing viral replication
Entry inhibitor-CCR5 coreceptor antagonists
HIV integrase strand transfer inhibitors
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Winter 2013
Antiretroviral Drugs Drugs (cont’d)(cont’d)
Reverse transcriptase inhibitors (RTIs)◦Nucleoside RTIs (NRTIs)◦Nonnucleoside RTIs (NNRTIs)
Examples◦abacavir (Ziagen)◦delavirdine (Rescriptor)◦didanosine (Videx)◦lefavirenze (Sustiva)
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Winter 2013
Antiretroviral Drugs Drugs (cont’d)(cont’d)
zidovudine (Retrovir)◦First anti-HIV medication◦Nucleoside reverse transcriptase inhibitor
◦Can be given to pregnant HIV-positive women and newborn babies to prevent maternal transmission of HIV
◦Major dose-limiting adverse effect: bone marrow suppression
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Winter 2013
Antiretroviral Drugs Drugs (cont’d)(cont’d)
Protease inhibitors (PIs)◦Inhibit the protease retroviral enzyme, preventing viral replication
◦amprenavir (Agenerase)◦indinavir (Crixivan)◦nelfinavir (Viracept)◦ritonavir (Norvir)
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Winter 2013
Antiretroviral Drugs Drugs (cont’d)(cont’d)
Fusion inhibitors◦Inhibit viral fusion, preventing viral replication
◦A newer class of antiretroviral drugs
◦Example: enfuvirtide (Fuzeon)
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Winter 2013
Antiretroviral Drugs Drugs (cont’d)(cont’d)
CCR5 antagonist◦maraviroc (Selzentry)
HIV integrase strand transfer inhibitor◦raltegravir (Isentress)
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Winter 2013
Antiretroviral Drugs Drugs (cont’d)(cont’d)
Combinations of multiple antiretroviral medications are common
Adverse effects vary with each drug and may be severe; monitor for dose-limiting toxicities
Monitor for signs of opportunistic diseases
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Winter 2013
Nursing Nursing Implications Be sure to teach proper application
technique for ointments, aerosol powders, and so on
Emphasize hand washing before and after administration of medications to prevent site contamination and spread of infection
Instruct patients to wear a glove or finger cot when applying ointments or solutions to affected areas
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Winter 2013
Antitubercular Drugs
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Winter 2013
Antitubercular DrugsTuberculosis (TB)
◦Caused by Mycobacterium tuberculosis
Antitubercular drugs treat all forms of Mycobacterium
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Winter 2013
Mycobacterium Infections
Common infection sitesLung (primary site)BrainBoneLiverKidney
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Winter 2013
Mycobacterium Infections (cont’d)
Aerobic bacillusPassed from infected:
◦Humans◦Cows (bovine) and birds (avian)
Much less common
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Winter 2013
Mycobacterium Infections (cont’d)
Tubercle bacilli are conveyed by dropletsDroplets are expelled by coughing or
sneezing, and then gain entry into the body by inhalation
Tubercle bacilli then spread to other body organs via blood and lymphatic systems
Tubercle bacilli may become dormant, or walled off by calcified or fibrous tissue
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Winter 2013
Antitubercular DrugsFirst-line drugs
◦ isoniazid (INH)*◦ethambutol◦rifampin◦rifabutin◦pyrazinamide (PZA)◦Rifapentine◦streptomycin
*Primary drug used
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Winter 2013
Antitubercular Drugs (cont’d)
Second-line drugs◦capreomycin◦amikacin◦cycloserine◦levofloxacin◦ethionamide◦ofloxacin ◦kanamycin◦para-aminosalicyclic acid (PAS)
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Winter 2013
Antitubercular Drug TherapyAntitubercular Drug TherapyConsiderationsConsiderations
Perform drug-susceptibility testing on the first Mycobacterium that is isolated from a patient specimen to prevent the development of MDR-TB
Even before the results of susceptibility tests are known, begin a regimen with multiple antitubercular drugs (to reduce chances of development of resistance)
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Winter 2013
Antitubercular Drug TherapyConsiderations ( (cont’d))
Adjust drug regimen once the results of susceptibility testing are known
Monitor patient compliance closely during therapy
Problems with successful therapy occur because of patient nonadherence to drug therapy and the increased incidence of drug-resistant organisms
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Winter 2013
Antitubercular Therapy
Effectiveness depends upon:◦Type of infection◦Adequate dosing◦Sufficient duration of treatment
◦Adherence to drug regimen◦Selection of an effective drug combination
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Winter 2013
Antitubercular Therapy (cont’d)
Problems◦Drug-resistant organisms◦Drug toxicity◦Patient nonadherence
Multidrug-resistant TB (MDR-TB)
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Winter 2013
Isoniazid (INH)Drug of choice for TBResistant strains of Mycobacterium
emergingMetabolized in the liver through acetylation
—watch for “slow acetylators”Used alone or in combination with other
drugsContraindicated with liver disease
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Winter 2013
Adverse EffectsINH
◦Peripheral neuropathy, hepatotoxicity
ethambutol◦Retrobulbar neuritis, blindness
rifampin◦Hepatitis; discoloration of urine, stools, and other body fluids
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Winter 2013
Nursing Implications
Perform liver function studies in patients who are to receive isoniazid or rifampin (especially in elderly patients or those who use alcohol daily)
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Winter 2013
Nursing Implications (cont’d)
Patient education is criticalTherapy may last for up to 24
monthsTake medications exactly as
ordered, at the same time every day
Emphasize the importance of strict adherence to regimen for improvement of condition or cure
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Winter 2013
Nursing Implications (cont’d)
Remind patients that they are contagious during the initial period of their illness—instruct in proper hygiene and prevention of the spread of infected droplets
Teach patients to take care of themselves, including adequate nutrition and rest
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Winter 2013
Nursing Implications (cont’d)
Patients should not consume alcohol while on these medications or take other medications, including over-the-counter medications, unless they check with their physician
Rifampin causes oral contraceptives to become ineffective; another form of birth control will be needed
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Winter 2013
Nursing Implications (cont’d)
Patients who are taking rifampin should be told that their urine, stool, saliva, sputum, sweat, or tears may become reddish orange; even contact lenses may be stained
Pyridoxine may be needed to combat neurologic adverse effects associated with INH therapy
Oral preparations may be given with meals to reduce GI upset, even though recommendations are to take them 1 hour before or 2 hours after meals
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Winter 2013
Nursing Implications (cont’d)
COMPLIANCE AND DOT THERAPY◦Because of the length of treatment, it is difficult to be sure patient will comply
◦Family education may improve compliance
◦DOT = DIRECT OBSERVATION THERAPY
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Antifungal Drugs
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Winter 2013
Indications
Systemic and topical fungal infections
Drug of choice for the treatment of many severe systemic fungal infections is amphotericin B
Choice of drug depends on type and location of infection
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Winter 2013
Adverse Effects: Amphotericin B
Fever Chills Cardiac dysrhythmias Nausea and GI upset Renal toxicity Headache Malaise Hypotension Tingling, numbness in hands and feet Lowered potassium and magnesium levels
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Winter 2013
Adverse Effects: Amphotericin B
(cont’d) Main concerns:
◦*Renal toxicity◦*Neurotoxicity: seizures and paresthesias
Many other adverse effects
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Winter 2013
Nursing Implications (cont’d)
amphotericin B◦To reduce the severity of the
infusion-related reactions, pretreatment with an antipyretic (acetaminophen), antihistamines, antiemetics, and corticosteroids may be given
◦Use an IV infusion pump
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Winter 2013