ANTIBIOTICS ANTIVIRALSA ANTIFUNGALS ANTI-TUBERCULAR ANTIMALARIAL ANTIHELMINTHIC ANTIMYCOBACTERIAL ANTIVIRALS ANTIBIOTICS COMMONLY KNOWN AS ANTIMICROBIALS - PowerPoint PPT Presentation

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ANTIBIOTICS ANTIVIRALSA ANTIFUNGALS ANTI-TUBERCULAR ANTIMALARIAL ANTIHELMINTHIC ANTIMYCOBACTERIAL ANTIVIRALS ANTIBIOTICS COMMONLY KNOWN AS ANTIMICROBIALS

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Title: ANTIBIOTICS ANTIVIRALSA ANTIFUNGALS ANTI-TUBERCULAR ANTIMALARIAL ANTIHELMINTHIC ANTIMYCOBACTERIAL ANTIVIRALS ANTIBIOTICS COMMONLY KNOWN AS ANTIMICROBIALS


1
ANTIBIOTICSANTIVIRALSAANTIFUNGALSANTI-TUBERCULA
RANTIMALARIALANTIHELMINTHICANTIMYCOBACTERIALAN
TIVIRALSANTIBIOTICSCOMMONLY KNOWN AS
ANTIMICROBIALS
DRUGS FOR BUGS ??
2
WHAT IS AN INFECTION?
  • A disease or condition caused by a microorganism
    that releases toxins or invade body tissues
  • Localized infection
  • Systemic infection

3
WHO IS MORE LIKELY TO GET AN INFECTION?
  • SKIN NOT INTACT
  • BLOOD SUPPLY IMPAIRED
  • NEUTROPENIA
  • MALNUTRITION
  • SUPPRESSION OF NORMAL BACTERIAL BALANCE
  • SUPPRESSION OF THE IMMUNE SYSTEM
  • DIABETES
  • CHRONIC ILLNESS
  • ADVANCED AGE

4
Infections 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

5
Infections Sites of Origin (contd)
  • 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

6
Healthcare-Associated Infections Prevention
  • Hand washing
  • Antiseptics
  • Disinfectants

7
Healthcare-Associated Infections Prevention
(contd)
  • 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

8
FUNCTIONS OF ANTIBIOTICS
  • BACTERICIDAL Kills or destroys microorganisms
  • BACTERIOSTATIC Retards the growth of
    microorganisms

9
IDENTIFICATION OF BACTERIA
  • GRAM TESTING
  • CULTURE AND SENSITIVITY TESTING
  • SEND SPECIMEN FIRST !!!!!
  • START ANTIBIOTIC BEFORE CULTURE RESULTS ARE KNOWN
    (EMPIRIC THERAPY)
  • RX MAY CHANGE WHEN CULTURE IS GROWN

10
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11
BACTERIAL RESISTANCE
  • Bacterial resistance
  • PENICILLINASE
  • USED BY BACTERIA TO DESTROY PCN
  • BETA-LACTAMASE
  • BREAKS DOWN THE STRUCTURE OF THE ABX INACTIVATING
    THE DRUG

12
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

13
ANTIMICROBIAL RESISTANCE
  • METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS
    MRSA
  • HAND WASHING AND GLOVING
  • GOAL IS TO AVOID HEALTHCARE ASSOCIATED INFECTIONS
  • COLONIZED MEANS HARBORS THE BACTERIA

14
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

15
ADVERSE REACTIONS TO ABX
  • HYPERSENSITIVITY (allergy)
  • Requires at least one exposure to the drug
  • Mild
  • Rash, pruritus, urticaria
  • Severe
  • Anaphylaxis
  • Laryngospasms (wheezing)
  • Dyspnea
  • Decrease in blood pressure

16
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18
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

19
STEVENS-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.
  • TABERS TOXIC EPIDERMAL NECROLYSIS

20
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23
SUPERINFECTION
  • A secondary infection that occurs during
    antibiotic therapy in which normal flora are
    destroyed

24
Superinfection
  • LOCATION OF INFECTION
  • GROIN
  • AXILLA
  • MOUTH
  • UNDER BREAST TISSUE
  • ANY WARM MOIST AREA
  • OFFENDING ORGANISM
  • YEAST
  • BACTERIA

25
Candida Yeast / Thrush
26
NURSING RESPONSIBILITIES
  • PATIENTS 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

27
CHARACTERISTICS OF ANTIBACTERIALS
  • BROAD SPECTRUM
  • NARROW SPECTRUM
  • MECHANISM OF ACTION

28
BROAD SPECTRUM ANTIBIOTIC
  • 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

29
NARROW SPECTRUM ANTIBIOTIC
  • AN ANTIBIOTIC EFFECTIVE AGAINST A LIMITED NUMBER
    OF MICROORGANISMS.
  • EXAMPLES OF NARROW-SPECTRUM AGENTS INCLUDE
  • PENICILLIN G
  • MACROLIDES
  • NITROFURANTOIN
  • METRONIDAZOLE
  • AZTREONAM
  • NALIDIXIC ACID

30
MECHANISMS OF ACTION
  • Inhibition of bacterial cell wall synthesis
  • Inhibition of protein synthesis
  • Disruption of cell membranes
  • Inhibits cell reproduction
  • Inhibits cell metabolism

31
Antibiotics Sulfonamides
  • One 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

32
Sulfonamides Mechanism of Action
  • Bacteriostatic action
  • Prevent 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

33
Sulfonamides 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

34
Sulfonamides Indications (contd)
  • Urinary tract infections
  • Upper respiratory tract infections

35
Sulfonamides Adverse Effects
  • Body System Adverse Effects
  • Blood Hemolytic and aplastic anemia,
    agranulocytosis, thrombocytopenia
  • Integumentary Photosensitivity, exfoliative
    dermatitis, Stevens-Johnson syndrome, epidermal
    necrolysis

36
Sulfonamides Adverse Effects (contd)
  • Body System Adverse Effects
  • GI Nausea, vomiting, diarrhea, pancreatitis
  • Other Convulsions, crystalluria, toxic
    nephrosis, headache, peripheral neuritis,
    urticaria
  • http//www.youtube.com/watch?vifQMm2xuyqcplaynex
    t1listPL27024F7449C9E999featureresults_main

37
Beta-Lactam Antibiotics
  • Penicillins
  • Cephalosporins
  • Carbapenems
  • Monobactams

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39
Penicillins
  • First introduced in the 1940s
  • Bactericidal inhibit cell wall synthesis
  • Kill a wide variety of bacteria
  • Bacteria produce enzymes capable of destroying
    penicillins
  • These enzymes are known as beta-lactamases
  • As a result, the medication is not effective

40
Penicillins
  • Natural penicillins
  • Penicillinase-resistant penicillins
  • Aminopenicillins
  • Extended-spectrum penicillins

41
Penicillins (contd)
  • Natural penicillins
  • penicillin G, penicillin V potassium
  • Penicillinase-resistant drugs
  • cloxacillin, dicloxacillin, nafcillin, oxacillin

42
Penicillins (contd)
  • Aminopenicillins
  • amoxicillin, ampicillin
  • Extended-spectrum drugs
  • piperacillin, ticarcillin, carbenicillin
  • Usually used with other drugs rarely used alone

43
Penicillins (contd)
  • 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

44
Penicillins (contd)
  • Penicillinbeta-lactamase inhibitor combination
    drugs
  • Ampicillin sulbactam Unasyn
  • Amoxicillin clavulanic acid Augmentin
  • Ticarcillin clavulanic acid Timentin
  • Piperacillin tazobactam Zosyn

45
Penicillins Indications
  • Prevention and treatment of infections caused by
    susceptible bacteria, such as
  • Gram-positive bacteria
  • Streptococcus, Enterococcus, Staphylococcus

46
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

47
Penicillins Adverse Effects (contd)
  • Common adverse effects
  • Nausea, vomiting, diarrhea, abdominal pain
  • Other adverse effects are less common

48
Penicillins Interactions
  • MANY interactions!
  • NSAIDs
  • Oral contraceptives Decreases effectiveness
  • Warfarin Enhanced anticoagulant effect r/t
    decrease in intestinal flora producing vitamin K
  • Others

49
MRSA
  • METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS
  • Hand washing and gloving
  • Goal is to avoid healthcare associated infections
  • Colonized means harbors the bacterial infection

50
NURSING CONSIDERATIONSFOR PENICILLIN
  • Take with a full glass of water
  • Do not skip doses
  • Take all of the medication as prescribed
  • Notify MD of adverse reactions

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52
Cephalosporins
  • First generation
  • Second generation
  • Third generation
  • Fourth generation
  • Fifth generation (not yet marketed)

53
Cephalosporins (contd)
  • Semisynthetic derivatives
  • Structurally and pharmacologically related to
    penicillins
  • Bactericidal action
  • Broad spectrum
  • Divided into groups according to their
    antimicrobial activity

54
Cephalosporins First Generation
  • Good gram-positive coverage
  • Poor gram-negative coverage
  • Parenteral and PO forms
  • Examples
  • cefadroxil
  • cephradine
  • cefazolin
  • cephalexin

55
Cephalosporins First Generation (contd)
  • Used for surgical prophylaxis, and for
    susceptible staphylococcal infections
  • cefazolin (Ancef and Kefzol) IV or IM
  • cephalexin (Keflex) PO

56
Cephalosporins Second Generation
  • Good gram-positive coverage
  • Better gram-negative coverage than first
    generation
  • Examples
  • cefaclor
  • cefprozil
  • cefoxitin
  • cefuroxime
  • loracarbef
  • cefotetan

57
Cephalosporins Second Generation (contd)
  • cefoxitin (Mefoxin) IV and IM
  • Used prophylactically for abdominal or colorectal
    surgeries
  • Also kills anaerobes
  • cefuroxime
  • Zinacef is parenteral form Ceftin is PO
  • Surgical prophylaxis
  • Does not kill anaerobes

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

59
Cephalosporins Third Generation (contd)
  • 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

60
Cephalosporins Third Generation (contd)
  • 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

61
Cephalosporins Fourth Generation
  • Broader spectrum of antibacterial activity than
    third generation, especially against
    gram-positive bacteria
  • Uncomplicated and complicated UTI
  • cefepime (Maxipime)

62
Cephalosporins Fifth Generation
  • Ceftobipriole (not available)
  • Broader spectrum of antibacterial activity
  • Effective against a wide variety of organisms
  • MRSA
  • Pseudomonas

63
Cephalosporins Adverse Effects
  • Similar to penicillins
  • Mild diarrhea, abdominal cramps, rash, pruritus,
    redness, edema
  • Potential cross-sensitivity with penicillins if
    allergies exist

64
Carbapenems
  • Very broad-spectrum antibacterial action
  • Reserved for complicated body cavity and
    connective tissue infections
  • May cause drug-induced seizure activity
  • This risk can be reduced with proper dosage
  • All given parenterally

65
Carbapenems
  • imipenem/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)

66
Monobactams
  • Aztreonem (Azactam) Only drug in this catagory
  • Beta-lactam antibiotic
  • Gram negative bacteria
  • Inhibits cell wall synthesis
  • Common adverse effects

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?v2g-2oLb0IQwfeature
    related

68
MacrolidesMechanism of Action
  • Prevent protein synthesis within bacterial cells
  • Considered bacteriostatic
  • Bacteria will eventually die
  • In high enough concentrations, may also be
    bactericidal

69
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

70
Macrolides Indications (contd)
  • 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

71
Macrolides Indications (contd)
  • 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.

72
Macrolides Adverse Effects
  • 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

73
Ketolide
  • telithromycin (Ketek)
  • Only drug in this class
  • Better antibacterial coverage than macrolides
  • Active against gram-positive bacteria, including
    multidrug-resistant strains of S. pneumoniae
  • Associated with severe liver disease
  • Use is limited

74
Tetracyclines
  • demeclocycline (Declomycin)
  • oxytetracycline
  • tetracycline
  • doxycycline (Doryx, Vibramycin)
  • minocycline
  • tigecycline (Tygacil)

75
Tetracyclines (contd)
  • Natural and semisynthetic
  • Obtained from cultures of Streptomyces
  • Bacteriostaticinhibit bacterial growth
  • Inhibit protein synthesis
  • Stop many essential functions of the bacteria

76
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

77
Tetracyclines (contd)
  • 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

78
Tetracyclines Adverse Effects
  • 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?vAMAqU7MJ_sc

79
Tetracyclines Adverse Effects (contd)
  • Alteration in intestinal flora may result in
  • Superinfection (overgrowth of nonsusceptible
    organisms such as Candida)
  • Diarrhea
  • Pseudomembranous colitis

80
Tetracyclines Adverse Effects (contd)
  • May also cause
  • Vaginal candidiasis
  • Gastric upset
  • Enterocolitis
  • Maculopapular rash
  • Other effects

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Antibiotic Therapy Toxicities
  • Ototoxicity
  • Temporary or permanent hearing loss, balance
    problems
  • Nephrotoxicity
  • Varying degrees of reduced renal function
  • Rising serum creatinine may indicate reduced
    creatinine clearance
  • Monitor trough levels every 5 to 7 days while on
    therapy or as ordered
  • Monitor serum creatinine levels at least every 3
    days as an index of renal function

83
Aminoglycosides
  • gentamicin (Garamycin)
  • neomycin (Neo-fradin)
  • tobramycin (Nebcin)
  • amikacin (Amikin)
  • kanamycin
  • streptomycin

84
Aminoglycosides (contd)
  • Natural and semisynthetic
  • Produced from Streptomyces
  • Poor oral absorption no PO forms
  • Very potent antibiotics with serious toxicities
  • Bactericidal prevent protein synthesis
  • Kill mostly gram-negative bacteria some
    gram-positive also

85
Aminoglycosides Indications
  • 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

86
Aminoglycosides Indications (contd)
  • 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

87
Aminoglycosides Adverse Effects
  • Cause serious toxicities
  • Nephrotoxicity (renal damage)
  • Ototoxicity (auditory impairment and vestibular
    impairment eighth cranial nerve)
  • Must monitor drug levels to prevent toxicities

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Aminoglycosides Adverse Effects (contd)
  • Ototoxicity and nephrotoxicity are
  • the most significant
  • Headache
  • Paresthesia
  • Fever
  • Superinfections
  • Vertigo
  • Skin rash
  • Dizziness

90
Quinolones
  • ciprofloxacin (Cipro)
  • norfloxacin (Noroxin)
  • levofloxacin (Levaquin)
  • moxifloxacin (Avelox)

91
Quinolones (contd)
  • Also called fluoroquinolones
  • Excellent oral absorption
  • Absorption reduced by antacids
  • Effective against gram-negative organisms and
    some gram-positive organisms

92
Quinolones Mechanism of Action
  • Bactericidal
  • Alter DNA of bacteria, causing death
  • Do not affect human DNA

93
Quinolones Indications
  • Gram-negative bacteria such as pseudomonas
  • Respiratory infections
  • Bone and joint infections
  • GI infections
  • Skin infections
  • Sexually transmitted diseases
  • Anthrax

94
Fluoroquinolones Adverse Effects
  • Body System Adverse Effects
  • CNS Headache, dizziness, fatigue, depression,
    restlessness, insomnia
  • GI Nausea, vomiting, diarrhea, constipation,
    thrush, increased liver function studies, others
  • Cardiac Prolonged QT interval

95
Fluoroquinolones Adverse Effects (contd)
  • Body System Adverse Effects
  • Integumentary Rash, pruritus, urticaria,
    flushing, photosensitivity (with lomefloxacin)
  • Other Fever, chills, blurred vision, tinnitus
  • Black box warning increased risk of tendonitis
    and tendon rupture

96
Other Antibiotics
  • clindamycin (Cleocin)
  • linezolid (Zyvox)
  • metronidazole (Flagyl)
  • nitrofurantoin (Macrodantin)
  • quinupristin and Dalfopristin (Synercid)
  • daptomycin (Cubicin)
  • vancomycin (Vancocin)
  • colistimethate (Coly-mycin)

97
Other Antibiotics (contd)
  • clindamycin (Cleocin)
  • Used for chronic bone infections, GU infections,
    intra-abdominal infections, other serious
    infections
  • May cause pseudomembranous colitis

98
Other Antibiotics (contd)
  • 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

99
Other Antibiotics (contd)
  • metronidazole (Flagyl)
  • Used for anaerobic organisms
  • Intra-abdominal and gynecologic infections
  • Protozoal infections
  • Several drug interactions

100
Other Antibiotics (contd)
  • 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

101
Other Antibiotics (contd)
  • quinupristin and dalfopristin (Synercid)
  • 3070 combination, work synergistically
  • Used for bacteremia and infections caused by
    vancomycin-resistant Enterococcus (VRE) and other
    complicated skin infections
  • May cause arthralgias, myalgias

102
Other Antibiotics (contd)
  • daptomycin (Cubicin)
  • New class lipopeptide
  • Used to treat complicated skin and
  • soft-tissue infections

103
Other Antibiotics (contd)
  • 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

104
Other Antibiotics (contd)
  • vancomycin (Vancocin) (contd)
  • 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

105
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

106
Nursing Implications (contd)
  • 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

107
ANTIVIRAL MEDICATIONS
108
Understanding Viruses
  • Viral replication
  • A virus cannot replicate on its own
  • It must attach to and enter a host cell
  • It then uses the host cells energy to synthesize
    protein, DNA, and RNA

109
Understanding Viruses (contd)
  • Viruses are difficult to kill because they live
    inside the cells
  • Any drug that kills a virus may also kill
    cells

110
Viral Illnesses
  • Most viral illnesses are bothersome, but
    survivable
  • Effective vaccines have prevented some illnesses
  • Effective drug therapy is available for a small
    number of viral infections

111
Antiviral Drugs
  • Antiviral drugs kill or suppress the virus by
    destroying virions or inhibiting ability to
    replicate viruses controlled by current antiviral
    therapy

112
Antiviral Drugs (contd)
  • Viruses controlled by current antiviral therapy
  • Cytomegalovirus (CMV)
  • Hepatitis viruses
  • Herpes viruses
  • Human immunodeficiency virus (HIV)
  • Influenza viruses (the flu)
  • Respiratory syncytial virus (RSV)

113
Antiviral Drugs (contd)
  • Key characteristics of antiviral drugs
  • Able to enter the cells infected with virus
  • Interfere with viral nucleic acid synthesis
    and/or regulation
  • Some drugs interfere with ability of virus to
    bind to cells
  • Some drugs stimulate the bodys immune system

114
Antiviral Drugs (contd)
  • Opportunistic infections
  • Occur in immunocompromised patients
  • Would not normally harm an immunocompetent person
  • Require long-term prophylaxis and
  • antiinfective drug therapy
  • Can be other viruses, fungi, bacteria, or
    protozoa

115
Antiviral Drugs (contd)
  • 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

116
Virus Infections
  • Herpes-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?vMEvyptIJsuE
  • Epstein-Barr (HHV-4)
  • Cytomegalovirus (HHV-5)
  • Kaposis sarcoma (HHV-8)

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120
Antiviral Drugs (non-HIV)
  • Mechanism of action
  • Inhibit viral replication
  • Used to treat non-HIV viral infections
  • Influenza viruses
  • HSV, VZV
  • CMV
  • Hepatitis A, B, C (HAV, HBV, HCV)

121
Antiviral Drugs (non-HIV) (contd)
  • Adverse effects
  • Vary with each drug
  • Healthy cells are often killed also, resulting in
    serious toxicities

122
Antiviral Drugs (non-HIV) (contd)
  • 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

123
Antiviral Drugs (non-HIV) (contd)
  • rimantadine (Flumadine)
  • Same spectrum of activity, mechanism of action,
    and indications as amantadine
  • Fewer CNS adverse effects
  • Causes GI upset

124
Antiviral Drugs (non-HIV) (contd)
  • 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

125
Antiviral Drugs (non-HIV) (contd)
  • ganciclovir (Cytovene)
  • Synthetic nucleoside analog
  • Used to treat infection with cytomegalovirus
    (CMV)
  • Oral, parenteral forms
  • CMV retinitis
  • Ophthalmic form surgically implanted
  • Ocular injection (fomivirsen)

126
Antiviral Drugs (non-HIV) Dose-Limiting
Toxicities
  • ganciclovir
  • Bone marrow toxicity
  • foscarnet and cidofovir
  • Renal toxicity

127
Antiviral Drugs (non-HIV) 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

128
Antiviral Drugs (non-HIV) Ribavirin
  • Synthetic nucleoside analog
  • Given orally, or oral or nasal inhalation
  • Inhalation form (Virazole) used for hospitalized
    infants with RSV infections

129
HIV and AIDS
  • Human 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

130
Four Stages of HIV Infection
  • Stage 1 asymptomatic infection
  • Stage 2 early, general symptoms of disease
  • Stage 3 moderate symptoms
  • Stage 4 severe symptoms, often leading to death
  • WHO model

131
Opportunistic Infections
  • Protozoal
  • Toxoplasmosis of the brain, others
  • Fungal
  • Candidiasis of the lungs, esophagus, trachea
  • Pneumocystis jirovecii pneumonia, others
  • Viral
  • CMV disease, HSV infection, others

132
Opportunistic Infections (contd)
  • Bacterial
  • Various mycobacterial infections
  • Extrapulmonary TB
  • Opportunistic neoplasias
  • Kaposis sarcoma, others
  • HIV wasting syndrome
  • Major weight loss, chronic diarrhea, chronic
    fever

133
Antiretroviral Drugs
  • HAART
  • Highly active antiretroviral therapy
  • Includes at least three medications
  • Cocktails
  • These medications work in different ways to
    reduce the viral load

134
Antiretroviral Drugs (contd)
  • Reverse transcriptase inhibitors (RTIs)
  • Block activity of the enzyme reverse
    transcriptase, preventing production of new viral
    DNA
  • Protease 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

135
Antiretroviral Drugs (contd)
  • Reverse transcriptase inhibitors (RTIs)
  • Nucleoside RTIs (NRTIs)
  • Nonnucleoside RTIs (NNRTIs)
  • Examples
  • abacavir (Ziagen)
  • delavirdine (Rescriptor)
  • didanosine (Videx)
  • lefavirenze (Sustiva)

136
Antiretroviral Drugs (contd)
  • 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

137
Antiretroviral Drugs (contd)
  • Protease inhibitors (PIs)
  • Inhibit the protease retroviral enzyme,
    preventing viral replication
  • amprenavir (Agenerase)
  • indinavir (Crixivan)
  • nelfinavir (Viracept)
  • ritonavir (Norvir)

138
Antiretroviral Drugs (contd)
  • Fusion inhibitors
  • Inhibit viral fusion, preventing viral
    replication
  • A newer class of antiretroviral drugs
  • Example enfuvirtide (Fuzeon)

139
Antiretroviral Drugs (contd)
  • CCR5 antagonist
  • maraviroc (Selzentry)
  • HIV integrase strand transfer inhibitor
  • raltegravir (Isentress)

140
Antiretroviral Drugs (contd)
  • 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

141
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

142
Antitubercular Drugs
143
Antitubercular Drugs
  • Tuberculosis (TB)
  • Caused by Mycobacterium tuberculosis
  • Antitubercular drugs treat all forms of
    Mycobacterium

144
Mycobacterium Infections
  • Common infection sites
  • Lung (primary site)
  • Brain
  • Bone
  • Liver
  • Kidney

145
Mycobacterium Infections (contd)
  • Aerobic bacillus
  • Passed from infected
  • Humans
  • Cows (bovine) and birds (avian)
  • Much less common

146
Mycobacterium Infections (contd)
  • Tubercle bacilli are conveyed by droplets
  • Droplets 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

147
Antitubercular Drugs
  • First-line drugs
  • isoniazid (INH)
  • ethambutol
  • rifampin
  • rifabutin
  • pyrazinamide (PZA)
  • Rifapentine
  • streptomycin
  • Primary drug used

148
Antitubercular Drugs (contd)
  • Second-line drugs
  • capreomycin
  • amikacin
  • cycloserine
  • levofloxacin
  • ethionamide
  • ofloxacin
  • kanamycin
  • para-aminosalicyclic acid (PAS)

149
Antitubercular Drug TherapyConsiderations
  • 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)

150
Antitubercular Drug TherapyConsiderations
(contd)
  • 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

151
Antitubercular Therapy
  • Effectiveness depends upon
  • Type of infection
  • Adequate dosing
  • Sufficient duration of treatment
  • Adherence to drug regimen
  • Selection of an effective drug combination

152
Antitubercular Therapy (contd)
  • Problems
  • Drug-resistant organisms
  • Drug toxicity
  • Patient nonadherence
  • Multidrug-resistant TB (MDR-TB)

153
Isoniazid (INH)
  • Drug of choice for TB
  • Resistant strains of Mycobacterium emerging
  • Metabolized in the liver through
    acetylationwatch for slow acetylators
  • Used alone or in combination with other drugs
  • Contraindicated with liver disease

154
Adverse Effects
  • INH
  • Peripheral neuropathy, hepatotoxicity
  • ethambutol
  • Retrobulbar neuritis, blindness
  • rifampin
  • Hepatitis discoloration of urine, stools, and
    other body fluids

155
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)

156
Nursing Implications (contd)
  • Patient education is critical
  • Therapy may last for up to 24 months
  • Take medications exactly as ordered, at the same
    time every day
  • Emphasize the importance of strict adherence to
    regimen for improvement of condition or cure

157
Nursing Implications (contd)
  • Remind patients that they are contagious during
    the initial period of their illnessinstruct in
    proper hygiene and prevention of the spread of
    infected droplets
  • Teach patients to take care of themselves,
    including adequate nutrition and rest

158
Nursing Implications (contd)
  • 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

159
Nursing Implications (contd)
  • 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

160
Nursing Implications (contd)
  • 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

161
Antifungal Drugs
162
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

163
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

164
Adverse Effects Amphotericin B(contd)
  • Main concerns
  • Renal toxicity
  • Neurotoxicity seizures and paresthesias
  • Many other adverse effects

165
Nursing Implications (contd)
  • 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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