N3813

TEXAS WOMANS UNIVERSITY

COLLEGE OF NURSING
DALLAS CENTER
N3813: Pharmacology
Drugs for Infectious Diseases 20 questions
I. Basic Principles of Antimicrobial Therapy (Chapter 83)
Selective toxicity
A.
ability of a drug to injure a target cell or target organism without injuring other cells
1.
or organisms that are in intimate contact with the target
a. re: antibiotics ability of an antibiotic to kill or suppress infecting microbes
without causing injury to the host
b. must gain access to target sites
achieved by
2.
a. disruption of bacterial cell wall/membrane permeability bacterial lysis
b. inhibition of bacterial enzyme activity
c. disruption of bacterial protein synthesis
destroy/suppress the growth of infecting microorganisms so that normal defense
3.
mechanisms can control the infection
Classification
by antimicrobial mechanism of action
B.
different groups of antimicrobial agents treat different groups of microorganisms
1.
bactericidal versus bacteriostatic drugs can have both actions depending on dose
2.
administered and concentration at the site
adjuncts to other therapies surgery, wound debridement, incision and drainage
3.
(I&D), etc.
Infections
C.
local versus systemic (blood is contaminated with bacteria)
1.
a. bacteremia some bacteria in the blood
b. septicemia (sepsis) next step up, 1/3 people who are septic will die

Fever
definition: elevated body temperature, sign of inflammation
caused by pyrogens released from macrophages which interfere with the
temperature regulating centers located in the hypothalamus (bodys
thermostat)
role of fever bodys defense mechanism to kill off the bacteria and viruses
o constant fever that rises and falls only a few degrees typhoid
o intermittent fever returns to normal 1-3x/24 hours pyogenic infections
(pus-forming infection)
o remittent fever fluctuates but does not return to normal viral or bacterial
infections
o relapsing fever accompanied by afebrile episodes every few days malaria
o fever of unknown origin (FUO) T higher than 103F recorded daily for
more than 2 weeks with no diagnosis, brought into the hospital to
identify it usually through blood cultures, sometimes cancer
o hypothalmus no longer in contact with pyrogens T reset back to normal

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D.
E.

Flemming 1928, discovered penicillin

Drug resistant infections (resistance)
organism becomes less susceptible or not susceptible to antibiotic therapy
1.
statistics
2.
a. in 1941, every S. aureus strain was susceptible to penicillin now, more than 95%
of S. aureus strains are resistant
b. 2 million people in the US are infected with a drug resistant bacteria every year
c. 23,000 people die each year from drug resistant microbes
d. S. pneumoniae, the most common cause of pneumonia in adults and young
children, has shown a 300% increased rate of resistance to penicillin within the
past 5 years
resistance
develops by
3.
a. spontaneous mutation
b. conjugation transfer of genetic material multiple drug resistance
c. selective pressure as the susceptible microbial population is killed by effective
antibiotics, resistant pathogens multiply and take control as microbes develop
genes for resistance
possible reasons
4.
a. antibiotic cannot get to target site failure to complete full course of antibiotics
(more than of people polled by American Lung Association had prematurely
discontinued antibiotic use because they felt better) leads to remissions and
resistant strains, improper dosage
b. use of broad spectrum antibiotics kills a variety of bacteria, highly discouraged
c. antibiotics used drug-resistant microbes will emerge
inappropriate use of antibiotics for illnesses
i.
perceived need for antibiotics by the consumer inform them that they can
ii.
endanger the health of themselves or their children
antibiotics for plants, animals (Box 83-1) 80% of antibiotics are given to
iii.
animals
d. decreasing numbers of new antibiotics for use

5.

National Action Plan for Combating AntibioticResistant Bacteria (2015)

Slow the emergence and prevent the spread of resistant bacteria
Strengthen National One-Health Surveillance efforts to combat resistance
Advance development and use of rapid, innovative diagnostic tests for
identification of resistant bacteria
Accelerate research and development for new antibiotics and vaccines
Improve international collaboration and capacities for antibiotic-resistance
prevention, surveillance, control, and research/development
Establish antimicrobial stewardship programs in all acute care hospitals by 2020

strategies CDC program to prevent resistance

a. vaccinate*
b. get the catheters out less use of invasive devices (urinary catheters, IVs),
leading cause of nosocomial infections
c. target the pathogen pick the right drug for the bug
d. access the experts
e. practice antimicrobial control

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F.

f. use local data

g. treat infection, not contamination live through contamination
h. treat infection, not colonization
i. know when to say no to vancomycin (last resort)
j. stop treatment when infection is cured or unlikely
k. isolate the pathogen
l. break the chain of contagion wash your hands!
administration times spaced as evenly as possible to maintain a therapeutic level of
6.
antibiotic in the blood q6h, q8h
a. 9, 1, 5, 9 qid wont cut it, shouldnt go 12 hours w/o it
b. if they miss a dose, tell them to get back on it. Tell them that there is going to be a
problem if they arent consistent
Selection of antibiotics
identify the infecting organism
1.
a. optimize antimicrobial therapy match the drug with the bug
b. obtain specimen from the infected area if possible BEFORE initiating therapy
c. obtain culture and sensitivity reports BEFORE initiating therapy if possible
(otherwise, give drug based on best clinical evaluation)
determine
drug sensitivity of the infecting organism
2.
a. microorganism is susceptible to drug
examine host factors
3.
a. immune system + phagocytic cells
b. no antibiotic agent will affect a cure of an infectious process if host defense
mechanisms are inadequate
c. age
infants and elderly vulnerable to drug toxicity
i.
check relevant lab tests for all patients
ii.
correct therapeutic, high toxic, low subtherapeutic
a)
lowest level trough: blood is drawn immediately before administration
b)
highest level peak: blood is drawn shortly after drug given (look up
c)
time of peak level for the specific drug)
d. previous allergic reaction
more common with penicillins than any other antibiotic class
i.
ask them what the clinical manifestations to the drug
a)
hives/throat swells up bad, dont give it to them
b)
diarrhea normal...
c)
check allergy band
ii.
watch patient closely for at least a half an hour after administration of the drug
iii.
due development of anaphylaxis
most serious allergic reaction 600-800 people die annually [penicillins
a)
account for 75% of drug anaphylactic deaths + insulin, protamine sulfate,
cephalosporins], morality rate is 10%
massive release of histamine, leukotrienes, kinins, serotonin,
b)
anaphylatoxins
can occur in several seconds to 30 minutes after injection (immediate
c)
reaction), accelerated reaction 1-72 hours, late reaction days-weeks
stage of anaphylaxis
iv.
phase 1 skin
a)
diffuse flushing, itching, warm felling
i)

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hives on face, neck, chest

phase 2 body
b)
generalized body edema
i)
facial swelling + lips, tongue upper airway edema
ii)
iii) broncho/laryngospasm, choking, stridor, wheezing, SOB
iv) chest pain, tightness
severe hypotension shock
v)
vi) restlessness, dizziness, confusion loss of consciousness
treatment
stop the antibiotic!
a)
emergency situation ABCs establish/maintain airway, prevent CV
b)
collapse; the sooner you intervene the better
administer oxygen high flow at 15L/min
c)
IV therapy (NS or LR) 1-2 liters in first hour for volume expansion to
d)
maintain BP
drug therapy initiated immediately
e)
epinephrine 1:1000 0.5ml SQ q10-20min
i)
diphenhydramine (Benadryl) 50mg IM or IV
ii)
iii) aminophylline/theophylline bronchodilation
iv) albuterol by nebulizers
vasopressors hypotension
v)
vi) corticosteroids IV
ii)

v.

Characteristics

Difference
Incidence
Drug triggers
Cause

Onset
Course

Deadly Drug Induced Allergic Reactions

Toxic Epidermal Necrolysis
Stevens Johnson Syndrome
(TEN)
Rare, 0.4-1.3 cases per million
More common*
Mortality rate = 40%
7 cases per million
Lower mortality rate
Discovered in 1922
More than 30% sloughing of skin
10% sloughing of skin
(10%-30% known as SJS-TEN)
Confirmed by skin biopsy
More likely to effect the elderly +
More likely to effect patients under
Weakened immune system
the age of 40 + weakened immune
system
Dilantin, Tegretol, Fansidar,
Same +
Bactrim/Septra, + NSAIDS
Liver improperly breaks down a drug
and cant excrete it, byproducts build
up, bind with epidermal proteins
forming allergic compounds,
exaggerated response by immune
system to attack skin and mucous
membranes that have drug particles
bound to them
Multi-system organ failure--death
Fast onset: 1-3 days of starting drug
Slow onset: 1-14 days of starting
drug
3 phases:
1. nonspecific respiratory

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1. crescendo phase fever, malaise,

sore throat, runny nose, muscle aches,
skin tenderness
2. critical phase 2-3 days later, rash,
within 48 hours of the rash deadly
cascade of events with severe
epidermal detachment (entire top layer
of skin and all mucous membranes) +
multi-organ involvement, scalded skin
syndrome slight touch of the skin
causes it to peel off in sheets (looks
like a burn)
Risks: infection, fluid losses
(electrolyte changes)
3. convalescent phase epidermal
sloughing stops and healing begins
40-50% have eye involvement
Mucous membranes: lips, eyes,
mouth, nasal passages, stomach, anus,
genitalia
Nursing care

infection (fever, sore throat, chills,

malaise)
2. rash 1 to 3 days later
3. target lesions develop abruptly
and erupt over 2-4 weeks
(mistaken for chicken pox)
round, red, raised macules less
than 3cm diameter, irregular
borders, blistered, necrotic centers
face, trunk, palms hands, joint
area, soles of feet + blistering
lesions on at least 2 mucous
membranes
Respiratory tract involvement
usual,
Decreasing Temp means prognosis
is poor
Mucous membranes: lips, eyes,
mouth, nasal passages, stomach,
anus, genitalia

Discontinue drug!
Discontinue drug!
Transferred to burn center
(some antibiotics may be
Treatment is supportive
completed before sx)
Fluid and lyte replacement
Treatment is supportive
Nutritional support (TPN, enteral)
Fluid replacement
Pain management
Nutritional support
Thermoregulation
Meticulous eye care
Meticulous eye care
Thermoregulation
Infection control precautions
Antacids, sedation, analgesics
Surgical repair
No steroids
Physical therapy
Wound care
New treatment
Plasmphoresis, hyperbaric oxygen
Prophylactic use of antimicrobial drugs (30-50% of antibiotic use) one dose given via
G.
IV piggyback, very effective, part of the time-out
Surgery
1.
bacterial endocarditis
2.
neutropenia low WBCs prone to infection, give them antibiotics to help out the
3.
bodys mechanism
Suprainfection/superinfection
H.
new infection that appears during the course of antibiotic treatment for a primary
1.
infection one infection is replaced by another infection
common side effect that occurs during antimicrobial therapy
2.
reduction or eradication of normal microbial flora caused by the agents eliminate
3.
the inhibitory influence of normal flora
risk dosage #agents used broad spectrum agents
4.

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II. Drugs that Weaken the Bacterial Cell Wall I: Penicillins (Chapter 84)
Penicillins [Penicillin G or V, nafcillin (Unipen), ampicillin (Omnipen),
1.
amoxicillin (Amoxil), piperacillin (Pipracil)]
a. also known as beta-lactam antibiotics
b. 4 types narrow-spectrum (penicillinase sensitive), narrow-spectrum
(penicillinase resistant), broad-spectrum, extended-spectrum (Table 84-1)
c. developed in 1940s, very inexpensive
d. action effective against gram-positive bacterial (less gram-negative)
e. indications
infections caused by gram-positive bacteria, gram-negative cocci, anaerobic
i.
bacteria, spirochetes (ex: pneumonia, meningitis, gangrene, tetanus, anthrax)
?prophylaxis bacterial endocarditis (no clear evidence to support this use)
ii.
f. side effects
diarrhea from destruction of normal flora
i.
taste alterations metallic taste common
ii.
N, V
iii.
fungal superinfections sore mouth; dark, discolored sore tongue; vaginal
iv.
infection very common in women
neurotoxicity seizures, confusion, hallucinations
v.
pain at sites of IM injection antibiotic that squeezes through like toothpaste,
vi.
need 18 G needle OUCH!
vii. allergic reactions
most common cause of drug allergy (0.4% - 7%)
a)
no direct relationship between dosage and intensity of response
b)
prior exposure is necessary for an allergic reaction
c)
ask all patients if they have experienced an allergic reaction to
i)
penicillins
allergy to one PCN is considered an allergy to all PCNs
ii)
history
of reaction avoid PCN, if mild reaction give cephalosporins
d)
1% cross sensitivity with cephalosporins
i)
skin
testing for penicillin allergy
e)
allergy should be documented
i)
can decrease over time
ii)
g. drug interactions potassium-conserving drugs, aminoglycosides
h. route penicillin G (IM, IV), penicillin V (oral)
i. nursing implications
Be extra cautious when giving it for the first time, stay for 15 min after
i.
administering the medication
IM injections verify correct placement
ii.
oral penicillins bind to food to effectiveness empty stomach, no food at
iii.
least one hour before or 2 hours after administration
complete the entire course of therapy
iv.
monitor for adequate renal function (check I & O)
v.
watch for K or Na symptoms
vi.
vii. instruct patient to report any signs of allergic response
viii. monitor WBC, fungal infections
Memory Tip: Oral side effects are associated with penicillins (taste alteration, sore
mouth, and dark, discolored sore tongue) SO: Imagine taking a pen and coloring

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your tongue a dark color. This would taste funny and make your mouth sore. Pens
are also very useful and you can buy them cheap like penicillins.
III.Drugs that Weaken the Bacterial Cell Wall II: Cephalosporins, Carbapenems,
Aztreonam, Vancomycin, Teicoplanin, and Fosfomycin (Chapter 85)
Cephalosporins [cefazolin (Ancef) cefepime (Maxipime)] cefA.
classified by generations 1, 2, 3, 4 (18 agents)
1.
a. activity against gram-negative bacteria
b. resistance to beta-lactamases (produced by gram- bacteria)
c. ability to reach CSF
action bactericidal, disrupt cell wall synthesis, activate enzymes that cleave cell
2.
walls
route oral, IM (painful), IV
3.
side effects
4.
a. allergic reactions (rash can develop several days after onset of treatment)
b. bleeding tendencies (hypoprothrombinemia)
c. thrombophlebitis at IV site (infuse slowly)
d. diarrhea, abdominal cramps, GI upset
e. superinfection
f. nephrotoxicity
contraindications: renal disease, bleeding disorders, anticoagulants, probenecid
5.
antabuse-type reaction to alcohol intake (alcohol intolerance)
6.
a. causes palpatations, jitteriness
nursing implications
7.
a. never ingest alcohol in any form
b. monitor for superinfections especially in the elderly
c. monitor bleeding times, PT, bun
d. take oral cephalosporins with food if gastric upset occurs
e. refrigerate oral suspensions
Carbapenems [imipenem/cilastatin (Primaxin), meropenem (Merrem)]
B.
broadest antimicrobial spectrum of any drug
1.
indications treating mixed infections (anaerobes + S. aureus + gram-)
2.
route IM, IV
3.
side effects
4.
a. N, V, diarrhea
b. hypersensitivity reaction aka allergy
c. superinfections
vancomycin (Vancocin)
C.
action inhibit cell wall synthesis, bactericidal
1.
indications
2.
a. gram-positive infections only
b. *only serious, drug-resistant infections (MRSA) last resort drug*
c. antibiotic-associated pseudomembranous colitis (AAPMC)
caused by C. difficile (Box 85-1)
i.
life threatening infection, 90% of CD caused by antibiotics
a)
#1 cause of nosocomial infections in community hospital, > MRSA
b)
transmission: oral-fecal route, replicates in the colon
c)
symptoms: diarrhea, mucus/blood in stool, fever, anorexia, abdominal pain
d)
highly resistant to disinfection (patient rooms)
e)

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research: 59% HCW, 75% MDs had hand cultures + for c. difficile
treatment: vancomycin (IV only), metronidazole (Flagyl), fidoxomicin
g)
(Dificid) (PO)
inflammation or necrosis of the mucosal layers of the bowel wall
ii.
symptoms
iii.
abdominal pain/cramping, gas, severe/bloody diarrhea, fever
a)
weight loss
b)
fluid and electrolyte disruptions
c)
elderly susceptible
iv.
medical intervention necessary
v.
d. serious infections with susceptible organisms in patients allergic to PCN
route IV, oral route only for infections of the intestines (C. difficile)
3.
side effects
4.
a. ototoxicity/hearing loss (often reversible but can be permanent)
b. nephrotoxicity BUN, creatinine*
c. N, V, taste alterations (for po route)
d. Extravasation make sure that the IV is placed properly, otherwise it can cause
necrosis of the tissue
e. red-man syndrome (RMS)/red-neck syndrome
histamine release, chills, fever, increased HR, pruritus, burning, red (intense
i.
flushing) + macular rash on face/neck/torso/arms, hypotension
caused infusing via IV too quickly, now being seen with slower rate infusions
ii.
implication never infuse vancomycin < 60 minutes
iii.
reactions more likely to occur with patients under 40 particularly children
iv.
may need to give antihistamines before administration
v.
f. thrombophlebitis with IV infusion
contraindications: renal impairment, concurrent use of other ototoxic agents
5.
(aminoglycosides, amphotericin B, ASA, lasix)
nursing implications
6.
a. determine presence of hearing loss before and after drug therapy initiates
b. monitor serum peak and trough levels can fight resistance with therapeutic
levels
c. dosing according to weight
d. IV route irritating, rotate sites or use central access, assess for extravasation
e. no bolus IV administration
Memory Tip: Picture a red neck (no bolus administration to prevent histamine release)
driving a van (not a truck) with big guns in the seat next to him. When he shoots off
his big guns, it makes him loose some hearing (ototoxicity). He likes to use kidneys
for his target practice (nephrotoxicity).
f)

Process

Cause
Incidence

VRE
[vancomycin-resistant enterococcus]

MRSA
[methicillin-resistant staphylococcus aureus]

Overuse of antibiotics leading to once susceptible bacteria being resistant to previously

effective antibiotics
Reported in over 40 states, incidence
Once seen only in urban hospitals, MRSA
increasing due to over reliance on
is now occurring in nursing homes, long
vancomycin
term care facilities, and community
hospitals.
90% of staphylococcus strains are

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penicillin-resistant, 27% of staph strains

are resistant to methicillin [these strains
may also be resistant to cephalosporins,
aminoglycosides, tetracycline,
erythromycin, clindamycin]
Immunocompromised patients, burn
patients, intubated patients, central lines
insertion, surgical patients with large
wounds, dermatitis, prolonged hospital
stays, extended use of broad spectrum
antibiotics, patients with infections (blood,
lungs, etc.)
Infected patient or health care worker,
*Spread mainly on health care workers
hands* - silent carriers
Most frequent site of colonization is the
nose [40% of adults and children become
transient nasal carriers] diagnosed by
isolating bacteria from nasal secretions

People at risk

Immunosuppressed patients, patient who

have received vancomycin in the past,
patients with a urinary catheter or central
line catheter, elderly, renal failure patients,
surgical patients, exposure to VRE
contaminated equipment or patients

Transmission

Infected patient or health care worker,

Spread through direct contact between
infected agent [person or equipment] and
susceptible person,
VRE is capable of living for week on
surfaces [ex: gowns, bed linens, over bed
tables, etc.]

Prevention

Universal blood and body fluid

Eradicate MRSA colonization from the
precautions, body substance isolation
nares with topical mupirocin applied to
precautions
the nostrils, or topical plus oral antibiotics
Transmission based precautions for known
carriers [contact isolation]
General prevention of VRE and MRSA: wash your hands before and after caring for
any patient [most effective method to prevent contamination] even after wearing
gloves, use antiseptic soap, use contact isolation procedures, do not touch any
contaminated surface after removing gown/gloves, extra precautions with diarrhea/stool,
educate family members of proper procedures, do not share equipment between patients,
wipe down equipment after use
Options: do not treat the infection [allow
Vancomycin is the drug of choice with its
normal flora to repopulate], New drug:
associated side effects.
linezolid (Zyvox) and dalfopristin/
Daptomycin (Cubicin) used for IV
quinupristin (Synercid), new class of
treatment of skin infections, once daily
antibiotics (oxazolidinones), used for
alternative to vancomycin for MRSA.
VRE/MRSA, IV or po, SE: N, V, diarrhea, Tigecycline (Tygacil), ceftaroline fosamil
PC, LFTs, thrombocytopenia
(Teflaro) new IV cephalosporin for
MRSA

Treatment

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IV. Bacteriostatic Inhibitors of Protein Synthesis: Tetracyclines, Macrolides,

Clindamycin, Chloramphenicol, Linezolid, Dalfopristin/Quinupristin, and
Spectinomycin (Chapter 86)
Tetracyclines [tetracycline, doxycycline (Vibramycin), minocycline (Minocin)]
A.
action inhibit protein synthesis, bacteriostatic (short, intermediate, long acting)
1.
indication
2.
a. broad-spectrum antibiotics (gram-positive and gram-negative bacteria)
b. acne
c. PUD H. pylori
d. periodontal disease
extensive use has lead to bacterial resistance, use
3.
route oral, IM, IV
4.
side effects
5.
a. GI irritation epigastric burning, cramps, N, V, diarrhea
b. superinfection
due to broad spectrum range
i.
AAPMC
ii.
fungal overgrowth pruritus of rectum, genitals; sore mouth, tongue
iii.
c. effects on bones and teeth
binds to calcium in developing teeth yellow or brown spots
i.
*never give kids/pregnant women tetracycline
a)
hypoplasia of dental enamel
ii.
discoloration of permanent teeth (4 months to 8 years old)
iii.
suppress long bone growth in infants
iv.
d. hepatotoxicity
e. renal toxicity
f. photosensitivity
contraindications
6.
a. absorption of tetracylines with chelating agents
calcium supplements
i.
milk products
ii.
iron supplements
iii.
magnesium-containing laxatives
iv.
antacids
v.
b. patients with renal or liver failure
c. pregnant women, breast-feeding mothers, children less than 8 years
d. estrogen contraceptives effectiveness, you need to tell your patients, advise
them to use other means of protection for a week after finishing the antibiotics
nursing implications
7.
a. give with meals to GI upset but best if given on empty stomach because food
absorption, give at bedtime to GI irritation
b. administer at least 2 hours before or 2 hours after ingestion of chelating agents
c. advise patients to avoid prolonged exposure to sunlight, use sunscreen
Memory Tip: Picture a cyclone wiping out a broad area of Texas (broad spectrum
antibiotic). A pregnant woman, a child, and a cow get sucked up in the cyclone (but
they are of course ok : )). Cow calcium and dairy products decrease absorption of

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antibiotic. Use with caution for pregnant women, breastfeeding women, and
children.
B.

C.

D.

Macrolides [erythromycin, clarithromycin (Biaxin), azithromycin (Zithromax)]

action inhibit protein synthesis
1.
indications
2.
a. broad-spectrum antibiotics (pneumonia, pertussis, etc)
b. alternative for patients with PCN allergy
route oral, IV
3.
side effects (very safe)
4.
a. GI upset epigastric pain, N, V. diarrhea
b. liver injury N, V, abdominal pain, jaundice, LFTs
c. superinfection
d. hearing loss
e. cardiac dysrhythmias associated with this class of medication, doubled risk
contraindications
5.
a. theophylline serum levels
b. warfarin bleeding
c. hepatotoxic agents
d. antacids (Zithromax)
nursing implications
6.
a. give with meals to GI upset but best if given on empty stomach because food
absorption
b. check LFTs
c. educate patients about signs of liver injury and to notify their HCP
d. refrigerate oral suspensions, shake well; take full course of medication
e. treatment of group A beta-hemolytic strep infections take full course to prevent
acute rheumatic fever
Oxazolidinones [linezolid (Zyvox)]
bacteriostatic inhibitor of protein synthesis unique mechanism of action cross1.
resistance rare
indications aerobic and gram-positive bacteria
2.
a. MRSA
b. VRE
route oral (first oral drug for VRE), IV
3.
side effects
4.
a. diarrhea, N, V
b. HA
c. myelosuppression (leukopenia, thrombocytopenia, pancytopenia)
d. superinfection
e. liver injury
nursing implications
5.
a. perform CBC weekly
b. monitor LFTs
c. avoid MAOIs hypertensive crisis
Streptogramins [dalfopristin/quinupristin (Synercid)]
indication VRE, MRSA
1.
side effects
2.

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a. liver toxicity
b. infusion related thombophlebitis
nursing implications
3.
a. monitor LFTs
b. central line administration site preferred
c. very expensive ($3100)/5 days
V. Aminoglycosides: Bactericidal Inhibitors of Protein Synthesis (Chapter 87)
Aminoglycosides [gentamicin (Garamycin), tobramycin (Nebcin), amikacin (Amikin)]
A.
action disrupt protein synthesis, production of abnormal proteins, bactericidal
1.
indications
2.
a. narrow-spectrum antibiotics (narrow use)
b. serious infections due to aerobic gram-negative bacteria (E. coli, Klebsiella
pneumoniae, Pseudomonas aeruginosa, Serratia)
c. synergistic effect with PCN
route IV, IM, oral only for treatment of intestinal infections, topical
3.
side effects
4.
a. ototoxicity (inner ear)
hearing (cochlea hearing loss, high-pitched tinnitus (ringing in ears)
i.
balance (vestibular apparatus HA, N, unsteadiness, dizziness, vertigo)
ii.
irreversible
iii.
b. nephrotoxicity proteinuria, dilute urine, BUN/creatinine
c. neurotoxicity tingling of extremities, muscle twitching, convulsions
d. peripheral neuritis tingling in fingers and toes
e. optical neuritis loss of vision
f. allergic/hypersensitivity response
contraindications
5.
a. patients with renal disease (dosage size or dosing interval)
b. concurrent use of nephrotoxic agents (vancomycin, cephalosporins, amphotericin
B)
c. concurrent use of ototoxic agents (Vanco) ototoxicity when renal disease
present or administration of doses for more than 10 days
d. caution with patient who have hearing impairment
e. can intensify neuromuscular blockade induced by skeletal muscle relaxants,
caution with patient who have myasthenia gravis
dosing schedules once daily dosing, easier to take
6.
nursing implications
7.
a. monitor audiograms, renal function studies, vestibular function studies before,
during, after treatment
b. monitor peak and trough levels (trough more sensitive indicator of renal status)
c. monitor BUN and creatinine (especially in elderly), I & O
d. IV administer slowly to prevent neuromuscular blockade
e. force fluids to minimize irritation to urinary tubules
VI. Antimycobacterial Agents: Drugs for Tuberculosis, Leprosy, and
Mycobacterium avium Complex Infection (Chapter 90)
Tuberculosis
A.
global epidemic kills more people (2-3 million) than any other infectious disease
1.
worldwide, 2 billion people infected
a. 1998-current efforts have reduced the incidence below 1985 level (9.3 cases per
100,000 people)

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2.

3.

4.

5.

6.

7.

8.

b. 2/3 of reported cases occur in racial or ethnic minorities (Latinos, African

Americans)
c. more likely in people who live in course quarters
resurgence of TB
a. AIDS
b. emergence of multi-drug resistant mycobacteria, globalization caused the spread
of M tuberculosis to the rest of the world
c. major problem: prolonged treatment (6-9 months) + drug resistant TB strains
(caused by inadequate/incomplete treatment) + HIV/AIDS
caused by Mycobacterium tuberculosis
a. infections may be limited to the lungs or disseminated
b. can harbor bacteria but be asymptomatic (20% of persons infected with TB
develop active disease)
transmission
a. person to person by inhaling infected sputum that has been aerosolized
b. droplet nuclei of infectious particles of Mycobacterium tuberculosis
c. must inhale droplet nuclei (respiratory route only), prolonged exposure required
(close contacts such as family member, coworker, etc.)
d. can spread from lungs to other organs via the lymphatic and circulatory systems
symptoms
a. necrosis and cavitation of lung tissue death
b. cough more than 3 weeks + at least 2 other s/sx of TB: fever, chills, night sweats
(classic), fatigue, anorexia, unexplained weight loss, hoarseness
diagnosis
a. skin test, blood test
b. CXR (chest x-ray)
c. microbiologic evaluation of sputum
AFB sputum specimens and cultures (takes 2-12 weeks for culture results), 3
i.
consecutive days
MODS microscopic observation drug susceptibility faster, more accurate,
ii.
inexpensive
drug resistance
a. major barrier to successful therapy, risk of death
b. some bacilli are resistant to 1 drug, others to multiple drugs
c. infection with a resistant bacteria is acquired by
contact with a person who harbors resistant bacteria
i.
repeated ineffective courses of drug therapy (too short of duration,
ii.
subtherapeutic dose, poor compliance, too few drugs in combination used)
d. costs to treat drug resistant TB ($180,000 vs $12,000)
e. highest incidence in NYC (2/3 of all cases occur)
treatment
a. determine drug sensitivity testing
b. treatment initiated with 4-drug regimen (must include isoniazid + rifampin)
drug regimen including 4 or more drugs has a better chance of eradicating
organisms that could be resistant
c. drug-sensitive TB
2 months isoniazid + rifampin + pyrazinamide + ethambutol
i.
4 months isoniazid + rifampin
ii.
d. multi-drug resistant TB

N3813
14

resistance to at least isoniazid + rifampin

12-24 months after sputum conversion isoniazid + rifampin + pyrazinamide
ii.
+ ethambutol +kanamycin, amikacin, or capreomycin + ciprofloxacin or
ofloxacin + cycloserine, ethionamide, or para-aminosalicyclic acid
e. HIV
2-20% of patients with HIV infection develop active TB
i.
require more aggressive therapy
ii.
problem with drug interactions
iii.
f. sputum evaluated every 2-4 weeks initially, monthly after sputum cultures are
negative
precautions for nurses
9.
a. if suspect TB, start treatment right away with drug + isolation procedures (do not
wait for diagnostic study results)
b. instruct patients to use a tissue or hand to cover mouth and nose when coughing
or sneezing
c. wear N-95 mask during hospital transport and care
isoniazid (INH)
indication primary agent for treatment and prophylaxis of active and latent TB
1.
taken by all patients infected with isoniazid-sensitive strains of M. tuberculosis
2.
route oral, IM
3.
side effects
4.
a. peripheral neuropathy tingling, numbness, burning, pain of hands and feet
deficiency in Vitamin B6
i.
b. hepatotoxicity (with age), hepatitis TB drugs affect the liver (homeless
alcoholics?)
contraindications: patients with acute liver disease; caution with alcoholics, diabetics;
5.
Vitamin B6 deficiency, patients over the age of 50; caution with phenytoin(),
rifampin, pyrazinamide
nursing implications
6.
a. administer pyridoxine (Vitamin B6) as needed and to patients who are predisposed
to neuropathy
b. monitor LFTs
c. take drug on an empty stomach 1 hour before meals or 2 hours after
d. minimize alcohol ingestion
rifampin (Rifadin)
7.
a. indications one of most effective drugs for TB, leprosy
b. route oral, IV
c. side effects
hepatotoxicity, hepatitis
i.
discoloration of body fluids (urine, secretions), yellow eyes/skin
ii.
GI upset, flu-like symptoms
iii.
d. contraindications: effect of warfarin, oral contraceptives, certain HIV drugs,
caution with alcoholics
e. nursing implications
monitor LFTs
i.
take drug on an empty stomach 1 hour before meals or 2 hours after
ii.
warn patient of red-orange color to urine
iii.
advise women to use non-hormonal birth control
iv.
f. rifapentine (Priftin) long acting rifampin, first new TB drug in 10 years
i.

B.

N3813
15

INH + rifampin (Rifamate)

pyrazinamide
9.
a. indication in combination with other TB drugs
b. side effects
hepatotoxicity, hepatitis
i.
hyperuricemia
ii.
arthralgias, GI disturbances, rash, GI upset
iii.
c. contraindications: caution with patients with severe liver dysfunction, gout;
caution with alcoholics
d. nursing implications monitor LFTs every 2 weeks, risk with other TB drugs in
combination
INH
+ rifampin + pyrazinamide (Rifater)
10.
11. ethambutol (Myambutol)
a. indication early treatment of TB
b. side effects
optic neuritis blurred vision, constriction of visual field, disturbance of color
i.
discrimination (red/green)
allergic reactions
ii.
hyperuricemia - gout
iii.
GI upset, confusion
iv.
c. nursing implications
assess color discrimination and visual acuity prior to treatment and monthly
i.
not recommended for children less than 8 years old
ii.
monitor uric acid
iii.
take with food to GI upset
iv.
Miscellaneous Antibacterial Drugs: Fluoroquinolones, Metronidazole,
Rifampin, Bacitracin, and Polymyxins (Chapter 91)
Fluoroquinolones [ciprofloxacin (Cipro), moxifloxacin (Avelox), levofloxacin
(Levaquin)]
indications
1.
a. broad-spectrum antibiotic, aerobic gram-negative and some gram-positive
bacteria
b. UTI (literature recommends Bactrim not Cipro for uncomplicated cystitis)
c. gastroenteritis (Salmonella, E. coli)
d. bones/joint/skin infections, bronchitis, pneumonia
e. Cipro was DOC for anthrax
route oral, IV
2.
side effects
3.
a. GI reactions (N, V, diarrhea, abdominal pain)
b. CNS effects (dizziness, HA, restlessness, confusion)
c. superinfections fungal infections
d. arthralgia/tendon rupture
e. photosensitivity
f. crystalluria increase UO
g. allergic response
contraindications: absorption of Cipro with antacids, iron, zinc, sucralfate, dairy
4.
products; theophylline and warfarin
nursing implications
5.
a. monitor urine for crystals
8.

VII.
A.

N3813
16

B.

b. increase urine output over 1200cc/day

c. can be administered with meals or empty stomach
metronidazole (Flagyl)
action interacts with DNA inhibition of nucleic acid synthesis cell death
1.
indications
2.
a. protozoal infections (intestinal amebiasis, systemic amebiasis, trichomoniasis)
b. anaerobic bacteria, anything that is not exposed to air
c. prophylaxis for surgical procedures associated with risk of anaerobic infections
d. H. pylori
route oral, IV
3.
side effects
4.
a. GI upset (diarrhea, N, V, anorexia)
b. CNS effects (dizziness, HA)
c. metallic taste, dry mouth
d. peripheral neuropathy (numbness, tingling in hands and feet)
e. superinfections
f. allergic response
nursing implications
5.
a. monitor stool specimens for infection
b. administer with meals
c. avoid alcohol
d. urine may be darker in color

Memory Tip: Picture a funky-looking bug (trichomoniasis, intestinal amebiasis,

anaerobic bacteria all sound like bugs) carrying a flag (Flagyl). This bug is drunk
(drug interactions with alcohol), and because he is drunk, he is dizzy and has a
headache and is tingly all over. This flag is flying on a metal pole (metallic taste).
VIII. Antifungal Agents (Chapter 92)
amphotericin B (Fungizone)
A.
action permeability of fungal cell membranes (fungicidal/fungistatic depends on
1.
dosing concentration), very toxic
indications
2.
a. severe pathogenic fungal infections (drug of choice for systemic mycoses)
b. candidiasis
c. histoplasmosis
d. meningitis
e. fungal septicemia
route IV only
3.
treatment lasts 6-8 weeks to 3-4 months
4.
side effects
5.
a. infusion reactions
fever, chills, rigors, N, HA
i.
symptoms begin 1-3 hours after starting infusion and last 1 hour
ii.
reactions reduced by pretreatment protocol fluids, antipyretics, antiemetics,
iii.
antihistamines, morphine, steroids

N3813
17

B.

C.

D.

b. phlebitis, pain at infusion site always give through central line

c. nephrotoxicity dose limiting factor
d. hypokalemia
e. bone marrow suppression
contraindications: concurrent use of nephrotoxic agents, renal disease, drugs that
6.
cause potassium, digoxin
nursing implications
7.
a. determine causative fungal agent before treatment begins
b. monitor BUN/creatinine at least weekly, I & O
c. monitor K level
d. monitor CBC
e. administer using IV central line access, avoid peripheral routes
infuse carefully to avoid extravasation
i.
incompatible with many drugs check incompatibility chart
ii.
use in-line filter
iii.
infuse slowly over 2-6 hours, give on alternate days to side effects
iv.
f. kidney damage by infusing 1L NS on the day of drug administration
g. administer pretreatment drugs routinely
anidulafungin (Eraxis), micafungin sodium(Mycamine)
new type of antifungal echinocandin
1.
route IV
2.
side effects HA, N, rash, jaundice
3.
nursing implications
4.
a. less effect on electrolytes and kidneys
b. monitor liver function, blood chemistry
fluconazole (Diflucan)
action inhibits fungal growth, fungistatic
1.
less toxic than amphotericin B and only somewhat less effective (Table 92-1)
2.
indications one pill does the trick
3.
a. candidiasis vaginal, oropharyngeal, systemic
b. meningitis
c. histoplasmosis
routeoral, IV
4.
side effects
5.
a. GI upset (N, V, abdominal pain, diarrhea)
b. HA, photophobia
c. allergic response
d. liver injury (fatal hepatic necrosis)
contraindications: patients with liver disease, avoid drugs that gastric acidity
6.
fungal drug effects: avoid rifampin fungal drug effects; can cause toxic levels of
warfarin, phenytoin, statins
nursing implications
7.
a. monitor LFTs prior to treatment and at least monthly thereafter
b. do not use PPIs
c. single dose treatment available single 150mg dose can be curative for
vulvovaginal candidiasis
clotrimazole (Mycelex), nystatin (Mycostatin, Nilstat) oral suspension, miconazole
(Oravig) buccal
indication oral candidiasis (thrush)
1.

N3813
18

2.
3.
4.

route oral/local application, lozenge/oral suspension/troche, buccal

side effects
nursing implications
a. inspect oral cavity (especially of immunosuppressed patients or patients taking
antibiotics)
b. examine patient for cream-colored or bluish white patches of exudate on tongue,
mouth, pharynx
c. obtain culture before treatment begins
d. document the extent of the oral involvement
e. brush teeth before dose is administered
f. administration procedures
oral suspensions shake well, swish (retain as long as possible, several
i.
minutes is optimal) and swallow
troche dissolve slowly for 1530 minutes in the mouth (vaginal tablet can be
ii.
used as an oral lozenge) prolonged contact with mucosa desired [do not
chew or swallow whole]
buccal tablet applied to the upper gum just above the incisor tooth once
iii.
daily (press on upper lip for 30 sec to ensure adhesion), alternating sides of
the mouth each day, for 14 days
continue treatment for 48 hours after symptoms disappear
iv.

IX. Antiviral Agents I: Drugs for Non-HIV Viral Infections (Chapter 93)
acyclovir (Zovirax), valacyclovir (Valtrex)
A.
action suppressing synthesis of viral DNA
1.
indication drug of choice for herpes simplex viruses (genital herpes), herpes zoster
2.
(shingles) virus, varicella (chickenpox), cytomegalovirus (CMV)
does not cure herpes and will not prevent transmission of disease to others or
3.
recurrence, it will shorten the acute episode
route oral, IV, topical
4.
side effects
5.
a. N, V, diarrhea
b. phlebitis, inflammation at site of infusion
c. renal impairment, increase hydration
risk with dehydration hydrate during infusion and for 2 hours after with
i.
2000-4000cc/day
rapid infusion of IV route give slowly over 1 hour via IV pump
ii.
nursing implications
6.
a. monitor BUN, creatinine, I & O
b. use gloves to apply topical preparations
c. patient education
provide information about herpes (transmission, course, treatment)
i.
avoid sexual activity or use condom
ii.
take no longer than 6 months
iii.
wear loose-fitting clothes
iv.

N3813
19

get PAP test at least every year higher risk of cancer with herpes
oseltamivir (Tamiflu), zanamivir (Relenza)
B.
indication prevention and treatment of influenza
1.
route oral, oral inhalation (Diskhaler) Relenza
2.
the sooner you give it, the better it works
3.
begin treatment early no later than 2 days after symptom onset
4.
a. when treatment is started within 12 hours of symptom onset symptom
duration by 3 days
b. when treatment is started within 24 hours of symptom onset symptom
duration by 2 days
c. when treatment is started within 36 hours of symptom onset symptom
duration by 29 hours
severity of symptoms and incidence of complications
5.
side effects
6.
a. N, V give with food for po route
b. cough, throat irritation inhalation route
nursing implications
7.
a. use bronchodilator (asthma) before inhalation of Relenza
b. inhalation dose 2x/day for 5 days
X. Antiprotozoal Drugs I: Antimalarial Agents (Chapter 98)
Malaria
A.
parasitic disease caused by 4 different species of the protozoa Plasmodium
1.
kills less than TB but more than any other infectious disease (1-3 million deaths/year)
2.
75% of deaths occur in Africa (mostly in children under 5 years old)
3.
generally limited to tropical and subtropical areas
4.
1200 deaths/year in US usually acquired infection from traveling abroad not
5.
taking antimalarial chemoprophylaxis, inadequate amounts of medication, incorrect
medications
seek medical attention if develop fever during or 2 years after return
6.
Treatment
goals
B.
treatment of acute attack chloroquine
1.
prevention of relapse primaquine
2.
prophylaxis (suppressive therapy) no drug is 100% effective for prevention take
3.
protective measures, get quality drugs before travel chloroquine, mefloquine,
doxycycline, atovaquone/proguanil
chloroquine (Aralen), hydroxychloroquine (Plaquenil) quine
C.
action effective against certain forms of malaria, mechanism of action unknown
1.
indication
2.
a. prophylaxis, acute episodes
b. Plaquenil RA, SLE
c. systemic lupus erythematosus
route oral, IM
3.
side effects
4.
a. visual disturbances
blurred vision, difficulty reading
i.
*corneal opacities cataracts
ii.
retinopathy irreversible blindness at high doses
iii.
b. pruritis, hair loss, discoloration of skin/nails/mouth, HA
c. blood disorders
v.

N3813
20

D.

E.

d. GI distress abdominal discomfort, N, diarrhea, anorexia

contraindications: patients with liver disease
5.
nursing implications
6.
a. administer with meals, bitter taste
b. onset of action for RA is up to 6 months
c. recommend eye exam prior to treatment and q6months
d. monitor for the development of fever while traveling or within 2 months of travel
atovaquone/proguanil hydrochloride (Malarone)
indications prophylaxis and treatment
1.
mechanism of action disruption of DNA synthesis in the malarial parasite
2.
route oral
3.
side effects
4.
a. LFTs (25% will develop increased LFTs)****
b. abdominal pain, diarrhea, N, V, loss of appetite
c. HA, dizziness
d. hypersensitivity, rash/itching/SJS
nursing implications
5.
a. monitor LFTs
b. take the drug at the same time each day with food
c. monitor nutritional status due to GI side effects
primaquine phosphate (Primaquine)
indication prevention relapse of malaria
1.
route oral
2.
side effects
3.
a. hemolysis G-6-PD deficiency dark urine indicates presence of hemoglobin
nursing implications
4.
a. monitor CBC
b. drug can precipitate acute hemolytic anemia in patients with G-6-PD deficiency
c. examine urine after each voiding and report darkening of urine
Spelling Tips to Remember
Aminoglycosides
Penicillins
Cephalosporins
Erythromycins
Tetracyclines
Quinolones
Antivirals
Antifungals
TB

mycin
cillin
cef, ceph, kef
ilo, ithro
cycline
oxacin
vir
azole
rif

Study Questions
1.

A patient has been on antibiotics for approximately 4 days and develops a superinfection.
In the nurses explanation to her about superinfections, the nurse tells her that
superinfections develop:
a.
Rarely with the use of single drug therapy.

N3813
21

b.
c.
d.

Usually when large doses of antibiotics are used.

Whenever narrow spectrum antibiotics are indicated.
All of the time with any type of intravenous antibiotics.

2.

The rationale for the administration of prophylactic antibiotic therapy for a patient with
mitral valve prolapse is to prevent:
a.
Rheumatic fever recurrence after surgical treatment.
b.
Cardiovascular collapse during the dental work.
c.
Superinfections in the oral cavity.
d.
Subacute bacterial endocarditis.

3.

Intravenous Garamycin is discontinued, and a patient is sent home with a prescription for
tetracycline. It is crucial for the nurse to tell the patient to:
a.
Take the medication until he or she is feeling better.
b.
Avoid direct sunlight and ultraviolet rays during drug therapy.
c.
Keep the remainder of the medication in case of recurrence of infection.
d.
Take the medication with food and milk to minimize gastrointestinal irritation

4.

A patient is receiving metronidazole (Flagyl). Instructions to the patient should include

which of the following statements?
a.
"You may experience loss of appetite during the course of therapy."
b.
"Make sure to take this pill on an empty stomach."
c.
"This medicine may turn your saliva greenish-blue, so don't be alarmed."
d.
"Please call your physician if you experience fatigue, unusual bleeding, or
bruising."

5.

Muscular weakness and abdominal distention reflect which of the following side effects
associated with the use of amphotericin B?
a.
Hypokalemia
b.
Hypercalcemia
c.
Leukocytosis
d.
Agranulocytosis

6.

Pyridoxine is often indicated with the use of isoniazid. This concurrent use of Pyridoxine
is to prevent which of the following?
a.
Renal failure
b.
Hepatotoxicity
c.
Metabolic encephalopathy
d.
Peripheral neuritis