Metropolitan Community CollegeNursing ProgramNancy Pares, RN, MSN

Before Antibiotics◦ Infections treated topically with ‘poultice’ or

surgically removed 1936…Sulfonamide discovered

◦ Beginning of understanding of microbes 1941…Penicillin introduced

◦ WWII had great results with high volume data Present ….

◦ Man vs. microbe= resistant pathogens

Peak effect◦ 15-30 min after infusion has begun

Trough effect◦ Lowest point of medication effect◦ Draw blood just before the next scheduled dose

Barriers/prevention◦ Intact skin, adequate nutrition, respiratory cilia,

immune system

Seek and Destroy◦ WBC, adequate blood supply, intestinal flora,

vaginal flora, stomach acids

Virulence of the pathogen Number of pathogens Chronic illness Poor nutrition Diseases/drugs that decrease the immune

system Entry point Super infections

Status of immune system◦ May need prophylactic therapy

Location of the infection◦ Many drugs do not cross blood brain barrier

Extent of inflammation◦ Decrease circulation of drug

Age: metabolization of drug Pregnancy: risks to fetus vs. benefit of drug Genetics: enzyme deficiencies do not allow antibiotics

to clear system

Should be done before antibiotic initiated Microscopic examination

◦ Urine, stool, blood, spinal fluid, sputum, purulent drainage

◦ Identify the organism and test with antibiotics Culture and sensitivity testing

Preliminary results within 24 hours Final results in 2-3 days

Covered in objective 2

Passive immunity◦ A person has been given vaccine

Active immunity◦ Has had the disease

Acquired resistance◦ Bacteria have randomly mutated and can

transmit mutated bacteria to others◦ Healthcare practitioners role

Use antibiotics when indicated Prophylaxis: deep tissue injury, prosthetic heart

valves

Antibiotics do not create mutations

Narrow◦ Effective on limited number of organisms

Broad◦ Effective on many organisms; often used first

Bacteriocidal◦ Kills

Bacteriostatic◦ Prevents growth and reproduction

Hypersensitivity◦ Can result in anaphylactic shock/death

15% of penicillin users Treat with Benedryl, corticosteroids, epinephrine

◦ Cross sensitivity When antibiotics are closely related chemically

Organ toxicity◦ Liver, kidneys, CNS, GI is most common◦ Vancomycin highly nephrotoxic◦ Gentamycin highly ototoxic

Hematotoxicity◦ Chloramphenicol

Causes aplastic anemia Bone marrow cannot make red blood cells

Action/use◦ Kill bacteria by disrupting cell wall; chemical

make up responsible is beta lactam ring— some bacteria secrete enzyme that splits the beta

lactam ring allowing the bacteria to become resistant

◦ Chemical modifications Penicilinase resistant, broad spectrum, extended

spectrum◦ Treatment of pneumonia, skin, bone and joint

infections, blood infections, gangrene, meningitis

Routes◦ PO, IM, IV

Adverse effects◦ Hypersensitivity most common

Nursing considerations◦ VS, assess previous reactions, lab (electrolytes,

renal function, ECG, Observe for IV reaction within 30 min; client teaching; decrease effects of contraceptives; take on empty stomach

◦ Pen G Procaine—not given IV= lethal◦ Prototype: Pen G Potassium

Action/Use◦ Bacteriocidal by attaching to penicillin binding

proteins to inhibit cell wall synthesis◦ Gram negative infections and when less

expensive penicillins are not tolerated; 5-10% of people allergic to penicillin are also allergic to cephalosporins

Adverse reactions◦ Hypersensitivity; kidney toxicity

Prototype—Cefotaxime (Claforan)

First generation◦ Most effective against gram neg; beta lactamase

producing organisms usually resistant Second generation

◦ More potent, broader spectrum, moderately resistant to beta lactamase organisms

Third generation◦ Longer duration of action, resistant to b-

lactamase◦ Drugs of choice for pseudomonas, klebsiella,

neisseria, salmonella and H. influenza Fourth generation-treat CNS infections

◦ Use: gram + cocci; gram - bacilli

Nursing considerations◦ Assess for bleeding disorders-check PT levels

Interferes with Vit K metabolism◦ Assess kidney and liver function labs

Important in Vit K production◦ Assess concurrent meds: (NSAIDS)◦ Monitor I&O◦ Assess GI symptoms◦ Client teaching

Cultured dairy (superinfection prevention); avoid alcohol use, complete full RX; IM inj. painful

Action/Use◦ Bacteriostatic; inhibits protein synthesis to slow

microbial growth◦ Rocky Mtn Spotted fever, typhus, cholera, Lyme

disease, peptic ulcers (caused by H. pylori), chlamydial infections

S/E◦ n/v, diarrhea, photosensitivity, permanent

discoloration of teeth <8 yo

Nursing considerations◦ Avoid use <8 yo, avoid sunlight/UV exposure;

monitor labs (CBC, liver function, kidney function)◦ Teach importance of oral and perineal hygiene

due to super infections◦ Do not take with milk products, iron supplements,

or antacids; wait 1-3 hrs before taking antacids; wait 2 hrs before and after taking lipid lowering drugs (Ca+ and iron bind with tetracycline)

◦ Decreases effectiveness of oral contraception◦ Prototype: tetracycline

Action/use◦ Bacteriocidal; inhibits protein synthesis◦ Aerobic gram neg bacteria (e. coli, seratia,

proteus, klebsiella, pseudomanas); administered with other antibiotic for entercocci infections.

S/E◦ Irreversible ototoxicity, nephrotoxicity,

respiratory paralysis Prototype: Gentamycin (Garamycin)

Nursing considerations◦ Monitor for ototoxicity (How?)◦ Monitor for nephrotoxicity (How?)◦ Provide optimal oral hygiene◦ IV administration should be done slowly◦ Poorly absorbed via GI—only route is IV◦ Monitor peak and trough levels for toxicity

Quinolones/fluoroquinolones◦ First introduced in 1962◦ Currently four generations

Macrolides◦ Low doses-bacteriostatic◦ High doses-bacteriocidal◦ Prototype: e mycin

Action/Use◦ Bacteriocidal;inhibit enzymes (DNA gyrase and

topoisomerase) to affect DNA synthesis;gram neg microbes

◦ Respiratory, GI, GU tracts; skin and soft tissue; newer agents very effective against anerobes

S/E/route◦ n/v; ADVERSE: dysrhythmias,liver failure and

CNS changes; not used in pregnancy; caution in children; oral BID

Prototype:Ciprofloxicin (Cipro) Most common= levaquin

Nursing considerations:◦ Assess hypersensititivity; report neurologic

effects◦ Phototoxicitity◦ Don’t take with vitamins/mineral supplements

(or wait 2 hrs before and after◦ Monitor labs◦ I & O◦ Take all the prescription

Action/Use◦ Binds to bacterial ribosome to inhibit synthesis

(act inside cell); bacteriostatic; effective against gram + and -;treats whooping cough,

◦ Legionaire’s disease, H. influenza and Mycoplasma pneumoniae

◦ Newer drugs synthesized from erythromycin—less GI disturbance

S/E—very few Prototype: erythromycin (E-Mycin)

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

excretion◦ Photosensitivity◦ Complete the course of treatment

Clindamycin (Cleocin)◦ Grm + and – effectiveness◦ Use: oral infections◦ Contraindication: hypersensitivity

Limited use due to association w pseudomenbranous colitis

Sulfonamides◦ Action:bacteriostatic, broad spectrum, used for

UTI◦ Classified by route of administration

Systemic and topical◦ Systemic

Sulfisoxazole (Gantrisin)◦ topical

Sulfadoxine (Fansidar)- not 1st choice drug◦ Contraindicated in pregnancy and infants < 2

years (promotes jaundice);low soluability causes crystals in urine

Vancomycin ( Vancocin)◦ Reserved for severe infections; most effective

with MSRA; need peak and trough labs◦ Sensititivity reaction: hypotension and rash with

rapid IV infusion (Red Man Syndrome)

Imipenim (primaxin)—carbapenem category◦ Bacteriocidal; preparation specific for IV vs IM◦ Stable for 4 hrs; synergistic effects with

aminoglycosides◦ Use; septicemia/bacterial meningitis

Ketolides◦ Use: respiratory infections◦ Low incidence of adverse effects

Glycylcyclines◦ Use: complicated skin infections; MSRA

Nursing Dx◦ Pain related to infection◦ Infection◦ Hyperthermia◦ Risk for injury related to adverse drug effects◦ Deficient knowledge related to drug therapy◦ Risk for deficient fluid volume r/t fever, diarrhea

from adverse drug effect◦ Risk for non compliance r/t deficient knowledge,

cost of drug, drug effects

Client will◦ Report diminished signs and symptoms of

infection; decreased fever and fatigue; increased appetite

◦ Be free from or experience minimal adverse effects

◦ Verbalize understanding of the drugs use, adverse effects and required precautions

◦ Demonstrate proper self administration

Monitor vs and symptoms of infections Monitor hypersensitivity reaction Monitor for severe diarrhea Admin drug as ordered Monitor for superinfection Precaution regarding OTC Monitor for photosensitivity Determine food and drug interactions Monitor IV site

Patient◦ reports diminished signs and symptoms of

infection, decreased fever◦ Is free from or experiences minimal adverse

effects◦ Verbalizes and understanding of the drugs use,

effects and precautions◦ Demonstrates proper self admin.

Tuberculosis:◦ Cause:

Mycobacterium tuberculosis

◦ Incidence:

◦ Treatment: prolonged due to cell wall resistance to penetration by anti infective drugs Multiple drug concurrently

Rifampin: used for H influenza

Isoniazid (INH)◦ Action:

Inhibits synthesis of cell wall

◦ Use: tuberculosis

◦ S/E Numbness of hands, feet; rash; fever Contraindicated: hepatic disease; do not take with

antacids

General Action:◦ Inhibit ergosteral synthesis

Amphoericin B (Fungizone)◦ Systemic

New class: echinocandins◦ Used for systemic mycoses◦ Caspofungin: treats aspergilosis

Azoles◦ Fluconazole (Diflucan)

Action/use Penetrates most body membranes; interferes with

synthesis of ergosterol

◦ Nystatin (Mycostatin) Superficial antifungal

Swish and swallow Glycemic control changes occur Do not use intravaginally with pregnancy or

lactating moms

Nonnucleoside reverse transcriptase inhibitors (NRTI)◦ Action: binds to viral transcript and dis allows

the DNA action◦ Prototype: efavirenz (Sustiva)

Nucleoside and nucleotide reverse transcriptase inhibitors (NNRTI)◦ Action: creates a defective DNA by replacing

one of the nucleotides◦ Prototype: Zidovudine (AZT)

Protease inhibitors◦ Lopinavir (Kalentra)

Combination drug of lopinavir and ritonavir Action: inhibits hepatic breakdown of lopinavir

Fusion inhibitor:◦ Action: blocks fusion of HIV viron to DC4

receptor

Assessment

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

To prevent…

To alleviate..

To improve…

Client teaching