Chapter 40 Antibiotics Affecting Protein Synthesis

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Aminoglycosides
The aminoglycosides have been in use since 1944. Effective antibiotics for treating severe infections. General use is limited because of the potential for serious adverse effects which are : Ototoxicity and nephrotoxicity Prototype drug: gentamicin.

Usually given intravenously : onset rapid

duration 6- 8 hrs.
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Gentamicin: Core Drug Knowledge

Pharmacotherapeutics Serious infections (such as urinary tract infections, peritonitis, endocarditis, sepsis, osteomyelitis)

Effective against gram negative bacilli

Pharmacokinetics Distribution: throughout the body (except CSF).

Higher concentration in kidneys than serum.

Pharmacodynamics Affects protein synthesis within the cell
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Gentamicin: Core Drug Knowledge (cont.)

Contraindications Pregnancy and lactation Precautions known allergy to any aminoglycoside

renal or hepatic disease, pre-existing hearing loss

Adverse effects Neurotoxicity, nephrotoxicity, & ototoxicity

Drug interactions
Acyclovir, amphotericin B, cephalothin, cisplatin, cyclosporine, loop diuretics, and vancomycin
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Gentamicin: Core Patient Variables

Health status Past medical and any kidney problems. Life span and gender Ototoxic to fetus, assess pregnancy status. Lifestyle, diet, and habits Assess the nutritional status of the patient. Dehydrated patients have an risk of nephrotoxicity Environment Assess environment where drug will be given.

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Gentamicin: Nursing Diagnoses and Outcomes

Risk for Injury related to potential drug-related allergic reactions or suppression of bone marrow function Desired outcome: the patient will remain free of injury and will contact the prescriber if unusual adverse effects occur. Desired outcome: the patient will avoid dehydration, maintain fluid intake, and contact the prescriber if diarrhea persists. Desired outcome: the patient will report any weight gain exceeding 3 lb to the health care prescriber.

Diarrhea related to drug effects

Excess Fluid Volume related to potential nephrotoxicity

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Gentamicin: Planning & Interventions

Maximizing therapeutic effects Make sure that patients receive the full course as prescribed at around-the-clock intervals. Do not give at the same time as some forms of penicillin (space the drugs 2 hrs. apart ) Minimizing adverse effects Maintain blood levels of gentamicin within a therapeutic margin that is very narrow. Monitor for signs of ototoxicity and nephrotoxicity.

Monitor peak and trough blood levels

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Peak and Trough Levels

Certain drugs require peak and trough levels These measure the amount of drug within the blood Peak levels are those that are the highest levels in the blood Peak levels are drawn 30 minutes after the completion of a 30 minute IV administration of Gentamycin Peak levels are drawn 30- 60 minutes after completion of IV administration of Vancomycin Trough Level is the lowest level of the drug in the blood Trough Levels are drawn just before the next dose of the drug is to be administered
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 Patient and family education

Gentamicin: Teaching, Assessment & Evaluations

Patient should not take drug if pregnant or breastfeeding. Teach patients how to identify, report, and manage signs and symptoms of allergic reaction and adverse effects. If pt. has experienced an allergic reaction , they should not take any drug that has micin in it.

Ongoing assessment and evaluation

Discuss the addition of other potentially nephrotoxic or ototoxic drugs

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Question
Gentamicin is effective against what organism(s)? A. Pseudomonas aeruginosa B. Proteus mirabilis C. Klebsiella D. Enterobacter E. All of the above

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Rationale
Gentamicin is effective against what organism (s)? E. All of the above Gentamicin is effective in managing infections caused by gram-negative bacilli. Susceptible organisms include Pseudomonas aeruginosa, Proteus mirabilis, Escherichia coli; Klebsiella, Enterobacter, Serratia, and Citrobacter species; and staphylococci. Gentamicin must be transported across the cell membrane in order to enter the cell and disrupt protein synthesis. This process requires oxygen; therefore, gentamicin and other aminoglycosides are ineffective against anaerobes.
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Clindamycin: Core Drug Knowledge

Pharmacotherapeutics Aerobic gram-positive cocci and several anaerobic gram-negative and gram-positive organisms. Pharmacokinetics Varies with route of administration. Metabolized: liver. Excreted: bile and urine.

Pharmacodynamics
Enters the bacterial cell and binds to bacterial ribosomes, suppressing protein synthesis.
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Clindamycin: Core Drug Knowledge

Contraindications pregnancy, and lactation

hypersensitivity
renal or hepatic dysfunction Adverse effects

Pseudomembranous colitis{Black Box warning} maculopapular rash, erythema, and pruritus , nausea and vomiting
Drug interactions are numerous

Very toxic drug

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Clindamycin: Core Patient Variables

Health status Assess for allergy to medication. Life span and gender Used in pregnancy only if benefit outweighs the risk Assess the growth and developmental level of the child or infant ( use cautiously in infants and children) Lifestyle, diet, and habits Assess lifestyle to ensure that drug will be given properly. Environment Assess environment where drug will be given.

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Clindamycin: Nursing Diagnoses and Outcomes

Risk for Injury related to allergic reactions Desired outcome: the patient will stop drug therapy and immediately report symptoms of allergic reaction to the prescriber.

Diarrhea related to drug effects

Desired outcome: the patient will avoid dehydration and report persistent diarrhea to the provider. Risk for Injury related to possible blood dyscrasias

Desired outcome: the patient will remain injury free throughout drug therapy.

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Clindamycin: Planning & Interventions

Maximizing therapeutic effects Make sure that the patient receives the full course of clindamycin as prescribed.

Coordinate the administration of drugs to decrease potential undesired interactions.

Minimizing adverse effects Clindamycin should be administered on an empty stomach with a full glass of water. Report diarrhea to the provider immediately. Always check that C & S reports indicate sensitivity to Clindamycin
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Clindamycin: Teaching, Assessment & Evaluations

Patient and family education
Advise patients to contact the prescriber immediately if they experience diarrhea. Teach patients to recognize and report symptoms of allergic reaction and superinfection. Ongoing assessment and evaluation Monitor the patient for the onset of diarrhea.

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Question
What is the most serious adverse reaction of clindamycin administration? A. Respiratory arrest

B. Pseudomembranous colitis
C. Ventricular tachycardia D. Ototoxicity

Answer : B

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Macrolide Antibiotics
The macrolide antibiotics have been in use since 1952. They are characterized by molecules made up of largering lactones.

Macrolides are bacteriostatic or bactericidal in susceptible bacteria.

Prototype drug: erythromycin ( E-mycin, Erythrocin Stearate)

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Erythromycin: Core Drug Knowledge

Pharmacotherapeutics More effective against gram positive organisms

Used for patients that are allergic to penicillin

Treating Legionnaire disease, Mycoplasma pneumoniae pneumonia, diphtheria,and chlamydial infections Pharmacokinetics

Drug is easily inactivated by gastric acid ( various formulations are available to prevent this)
Peak 14 hours ( orally) : 1 hour ( intravenously) Metabolized: liver. Excreted: urine & bile.

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Erythromycin: Core Drug Knowledge (cont.)

Pharmacodynamics Inhibiting protein synthesis

Contraindications and precautions

Allergy to medication
Adverse effects GI symptoms, urticaria, maculopapular rash, erythema, and interstitial nephritis

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Erythromycin: Core Patient Variables

Health status Assess medical history and allergies. Life span and gender Assess pregnancy and lactation status. ( excreted in breast milk at about 50% of maternal plasma concentrations which can cause diarrhea or superinfection in the infant) Lifestyle, diet, and habits

Avoid Grapefruit juice increases the serum concentration of erythromycin and may cause toxicity /side effects
Take medication 1 hr. before or 2 hrs. after a meal

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Erythromycin: Nursing Diagnoses and Outcomes

Risk for Injury related to possible allergic reactions Desired outcome: the patient will stop drug therapy and report any signs of allergic reaction immediately to the prescriber.

Diarrhea related to drug-induced GI upset

Desired outcome: the patient will avoid dehydration, maintain fluid intake, and contact the prescriber if diarrhea persists.

Risk for Infection related to potential for superinfection following drug therapy Desired outcome: the patient will contact the provider if any signs of superinfection occur, for example, sore throat or fever.

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Erythromycin: Planning & Interventions

Maximizing therapeutic effects Reconstitute IV Erythromycin with sterile water only.

Prepared infusion solutions that are stored at room temperature must be used within 8 hours.
Minimizing adverse effects Because erythromycin can be very irritating to veins, it is important to administer IV infusions over 30 to 60 minutes.

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Erythromycin: Teaching, Assessment & Evaluations

Patient and family education Encourage patients to take the complete course of antibiotics.

Advise patients to take erythromycin on an empty stomach (unless GI distress is unbearable)

Ongoing assessment and evaluation Monitor for signs of allergic reactions, resolution of presenting signs and symptoms of infection, and signs of superinfection.

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Rationale
Grapefruit juice will decrease the serum concentration of erythromycin. A. True

B. False
Answer : B Instruct the patient to avoid grapefruit or grapefruit juice because it increases the serum concentration of erythromycin and may cause adverse effects or toxicity.

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Chloramphenicol: Core Drug Knowledge

Antibiotic that also affects protein synthesis Pharmacotherapeutics True broad-spectrum antibiotic (effective against gram negative and gram positive organisms; not fungi) Pharmacokinetics Administered: oral and IV. Peak 13 hours.

Passes through the blood brain barrier

Pharmacodynamics Inhibiting the protein synthesis of bacterial cells.
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Chloramphenicol: Core Drug Knowledge

Precautions
This drug is relatively toxic and has a Black Box Warning To be used only in serious infections in which no other drug is effective or in patients with resistance or allergies Adverse effects Aplastic anemia, thrombocytopenia, and granulocytopenia ( depressed bone marrow function) Drug interactions Many different types of drugs
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Chloramphenicol: Core Patient Variables

Health status Assess medical history. Establish baseline labs, CBC , hepatic and renal function Life span and gender

Contraindicated in pregnancy since it can cause bone marrow depression or gray baby syndrome in the neonate.
Environment Assess environment where drug will be given.

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Chloramphenicol: Nursing Diagnoses and Outcomes

Risk for Injury related to drug-induced adverse effects, such as blood dyscrasias, gray baby syndrome, and CNS effects, including optic or peripheral neuritis, headache, depression, confusion, or delirium Desired outcome: regular and careful monitoring will protect the patient from permanent drug-related adverse effects. Risk for Impaired Skin Integrity, rash and pruritus, related to topical drug use Desired outcome: the nurse and patient will observe for and report signs of unusual skin reaction and contact the prescriber.

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Chloramphenicol: Planning & Interventions

Maximizing therapeutic effects Oral chloramphenicol should be administered on an empty stomach 1 hour before or 2 hours after meals.

Minimizing adverse effects

Monitor plasma concentrations at least weekly or more often in patients with hepatic or renal impairment.

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Chloramphenicol: Teaching, Assessment & Evaluations

Patient and family education

Explain the importance of completing therapy.

Teach patients the importance of measuring fluid intake and output accurately.

Ongoing assessment and evaluation

For patients receiving systemic therapy, coordinate serial monitoring of chloramphenicol plasma concentrations. ( peak and trough levels can be done)

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