MICROBE  Unicellular or small multicellular organisms PATHOGEN  Microbes capable of producing disease BACTERIA  Prokaryotes, single celled organisms lacking a true nucleus and nuclear membrane  Have rigid cell walls  The cell walls determine the shape of the bacteria  Reproduce by cell division about every 20 minutes Classification of Bacteria (1) Shape under a Microscope Bacillus or Rod shaped Cocci or Spherical shaped a. b. In clusters - Staphylococcus In chains – Streptococcus (2) Staining Properties


Gram (+) retains purple stain S. aureus Streptococcus pneumoniae Gram (-) not stained Neisseria meningitides Escherichia coli

(3) Toxins produced

(4) Production of Beta lactamase enzymes

ANTIMICROBIALS / ANTI-INFECTIVES    Substances that inhibit growth or kill microorganisms Drugs used to manage infections Drugs may be bacteriostatic or bactericidal depending on the dose and serum level Classification by Mechanism of Action • • • • • • Inhibition of bacterial cell wall synthesis Inhibition of protein synthesis Inhibition of nucleic acid synthesis Inhibition of metabolic pathways (Antimetabolites) Disruption of cell wall permeability Inhibition of viral enzymes

Classification by Susceptible Organism Antibacterial drugs Narrow spectrum Broad spectrum Myocobacterium Antiviral drugs Antiretroviral Antifungal drugs Antiparasitic drugs Antihelmintic drugs

SELECTIVE TOXICITY   The ability to suppress or kill an infecting microbe without injury the host An action of a drug on biochemical processes is more harmful to the microbe than to host cells The body’s defense mechanism works together with the antimicrobials to the stop the infectious process The body’s defense mechanism is influenced by age, nutrition, WBCs, Immunoglobulins, organ function, and circulation

ANTIMICROBIAL SENSITIVITY  The pathogen is inhibited and destroyed by a particular antimicrobial drug ANTIMICROBIAL RESISTANCE  The pathogen continues to grow despite the administration of drugs  An ever present danger to effectively managing infection Contributing Factors to Antimicrobial Resistance Production of Drug-Inactivating Enzymes Changes in Receptor Structure


Beta lactamase enzymes affect the beta lactam structure of penicillins and cephalosporins Alteration in penicillin-binding proteins (PCBs) decreases the affinity for binding beta lactam antibiotics

Changes in Drug Permeation and Transport Development of Alternative Metabolic Pathways


Mechanisms developed to make passing through the cell wall difficult

Sulfonamides is an antimetalite that inhibits the enzyme necessary to metabolize folic acid Some bacteria maybe able to bypass this inhibitory action

and poor patient adherence No less than four drugs are given at one time - General Considerations for Selecting Antimicrobial Therapy “ The Right Drug for the Right Bug” 1. Patient Assessment . Site of Infection a) b) c) d) Meninges – drugs cannot cross blood brain barrier Abscess – poorly vascularized. in mixed infections. below MIC Improper dosage or improper dosing interval Insufficient duration of therapy Prophylactic use should be limited to exposure to STDs. 2. Surgery. have been developed to treat vancomycin resistant microbes - Multiple Drug-Resistant Tuberculosis (MDR-TB) - Resistance is developed over the long course of TB treatment. but may last as long as 30 days or more 3. Drug Susceptibility • • • A Culture test determines which pathogen is present A Sensitivity test determines the susceptibility of the pathogen to a particular antibiotic Narrow spectrum drugs affects only few microorg. while phagocytosis are busy attacking the foreign object.Acquiring Resistance - Caused by prior and repeated exposure to an antimicrobial Change in the genetic composition of the microbe. Drug Dose • • 5. Identification of the Pathogen 2. which can last as long as 2 years The cause is inadequate therapy. Time to affect the pathogen • • • Sites that are difficult to achieve therapeutic concentration 6. it limits the potential for adverse effects. a random occurrence or DNA may have been acquired from an external source A form of sexual reproduction in which 2 individual microbes join in temporary union to transfer genetic material Drug concentration too low to kill microorganism. and for enhanced antibacterial action Disadvantages of Combination therapy include an increased risk of toxic and allergic reaction. duration too short. for development of resistance. pus impedes drug concentrations Endocarditis – vegetative growths are hard to penetrate Foreign objects like pacemaker or prosthetic joints. such as superinfection A Superinfection occurs during the course of treatment for a primary infection. and daptomycin (Cubicin).. Recurrent UTIs. Neutropenia. they are less able to attack the bacteria multiplying at the site 7. Two consequences can occur: (1) Secondary infection and the (2) development of drug-resistant microbes Combination therapy is used as an alternative to broad spectrum antimicrobials. and Bacterial Endocarditis 1. the (2) site of the infection. and the (3) presence or absence of host defenses Generally 7 to 10 days. Drug Spectrum • • • 4. to prevent drug resistance. Communityacquired Pneumonia and Meningitis Avoid using as prophylaxis in children and elderly Immunization of patients over 65 and under 2 yrs will decrease development of resistance - Vancomycin-Resistant Enterococci Enterococci are generally treated with combination antibiotics: Aminoglycoside with penicillin or ceh-phalosporin Linezolid (Zyvox). dose too low. Spontaneous Mutation Conjugation - Factors that Facilitate the Development of Resistance - Common Antibiotic-Resistant Microbes Methicillin-Resistant Staphylococcus Aureus (MRSA) Penicillin binding proteins have been altered Vancomycin is the drug of choice - Penicillin Resistant Streptococcus Pneumoniae Penicillin is frequently used in infections like Otitis media. and for superinfection The lowest effective dose (= / >MIC) Choose the agent that takes the shortest time to affect the pathogen It will depend on the (1) type of pathogen. dalfopristin-quinupristin (Synercid.

SOB is frequently the 1st symptom of anaphylaxis. It is treated with an antihistamine Severe is Anaphylactic shock: It results in vascular collapse. Cephalosporin Bacitracin . Nalixidic acid - Bacteriostatic effect. Rifampicin . bronchospasm. Vancomycin Enzymatic breakdown of cell wall Inhibition of enzyme in synthesis of cell wall Alteration of membrane permeability Amphotericin B . avoid antimicrobials that induce RBC lysis like sulfonamides  Environment Culture and Inherited Traits • • •  • Monitoring Antimicrobial Therapy   Keep the serum level within the therapeutic margin Monitor CBCs if antimicrobial causes anemia Liver and kidney function test for the very young and old   The most important element of patient education is to advise the patient to complete the entire course of the therapy. populations most vulnerable to drug toxicity. Interferes with the steps of metabolism within the cells Isoniazid (INH) . bronchodilators. Colistin - Bacteriostatic or bactericidal Membrane permeability increased. Lincomycin Tetracycline . and cardiac arrest.  Health Status Life Span and Gender • • Immune status of the patient and Previous allergic reaction Elderly and Infants.and hives. Taking the prescribed dose at the prescribed intervals TYPE Allergy or Hypersensitivity General Adverse Reactions to Antibacterial Drugs Considerations - Mild allergic reaction: rash. Loss of cellular substances causes lysis of the cell Inhibition of protein synthesis Aminoglycoside . respiratory tract. Tetracycline induced gray mottled enamel Nursing child. It requires treatment with epinephrine. Erythromycin - Bacteriostatic or bactericidal effect Interferes with protein synthesis without affecting normal cell. Sulfonamide induced kernicterus (hyperbilirubinemia) IV route achieves the highest serum concentration of the antimicrobial but also the high potential for severe adverse effect (Amphotericin B IV administration requires hospital admission) Predisposition to glucose-6-phosphate deficiency (G6PD). intestine. pruritus. Inhibits steps of protein synthesis Inhibition of synthesis of bacterial RNA and DNA • Fluoroquinolones Interference of cellular metabolism • Sulfonamides - Inhibits synthesis of RNA and DNA in bacteria. and antihistamines Superinfection - A secondary infection that occurs when normal microflora of the body are disturbed during antibiotic therapy Rarely develops when drug therapy last < a week Commonly occurs with the use of broad spectrum antibiotics Superinfections can occur in the mouth. may request for lower doses During pregnancy. Binds to nucleic acid and enzymes needed for nucleic acid synthesis • • Trimethoprim . laryngeal edema. GUT or skin Nystatin is used for fungal infections of the mouth Liver and Kidney Aminoglycosides is neprotoxic and ototoxic Mechanism of Actions of Antibacterial Drugs - Organ toxicity ACTION Inhibition of cell wall synthesis Bactericidal effect EFFECT • • • • • • Penicillin . Nystatin Polymyxin .

skin infections Advantages : higher oral absorption. IV. aureus Combined with aminoglycosides to combat Pseudomonas PO. only Ampicillin is available PO and IV Broader spectrum than aminoampicillins Easily inactivated by penicillinase produced by S. low solubility (duration 12 weeks). stored in the refrigerator. coli. IM Resistance to Methicillin implies resistance to this class of penicillin PO. 1º used to treat Syphilis Acid stable form of Penicillin G Given on empty stomach 1 hr before or 2-3 hrs after meals with a full glass of water Effective against many gram negative microrg. Non-penicillinase producing Staphylococci. IM. fever. gastritis Caused by loss of normal flora and subsequent opportunistic infection • • Superinfections - Mouth ulcers. glossitis. rash. Shigella. abdominal pain. diarrhea. E. Treponema pallidum (Syphilis) Prophylaxis to prevent Bacterial endocarditis Useful in treating meningitis Unstable in gastric acid Salts of Na and K are aqueous and crystalline forms Salts of Procaine and Benzanthine are repository forms Procaine is milky in color. Streptococci. higher serum levels and longer half lives Route: All Oral. Salmonella. spirochetes. IV PENICILLINS (1) Narrow Spectrum • Penicillin G ( IM / IV )     Salts Salts Salts Salts of of of of Na K Procaine (IM only) Benzanthine • • • • • • Penicillin V (Oral) (2) Broad Spectrum “Aminopenicillins” - (3) Extended Spectrum “Antipseudomonal penicillins” - (4) Penicilinase. anaphylaxis • • • Nursing Intervention Skin test Monitor vital signs first 30 mins after IV administration Epinephrine and Respiratory support must be available Small frequent meals Mouth care with nonirritating (nonalcoholic) solution Adverse Effects Allergic reaction GI Upset - N & V. Proteus mirabilis Ineffective against penicillinase producing Staphylococcus aureius Oral dosage is indicated for many pediatric infections like Otitis media.PENICILLINS      1st antibiotic introduced for clinical use (1929) Alexander Fleming (Nobel Prize winner).Resistant “Antistaphylococcal penicillins” -  Mechanism of Action: Inhibits bacterial wall synthesis Signs and Symptoms Itching. beta lactam structure essential for antibacterial activity Difficult to maintain therapeutic levels because they are rapidly cleared from the plasma by the kidneys Contraindicated for any known allergy to penicillin or cephalosporin Classification Considerations Gram + bacteria. Tonsillitis. stomatitis. wheezing (SOB). furry tongue Yeast infections (antifungal meds) Genital discharge (vaginitis). Haemophilus influenza. anaerobes. Pneumonia.derived them from Penicillum molds Beta lactam antibiotic. anal or genital itching • • Ice chips for stomatitis and sore mouth or pain Report and arrange for appropriate treatment Culture and Sensitivity test (C&S) before treatment Aspirate to avoid injection of vasculature (IM) Assess landmarks to avoid injection of nerve Provide warm compress and gentle massage to painful and swollen injection sites Observe sterile technique • • • • • Injection sites Reactions - Local pain or inflammation (monitor & rotate injection sites) Phlebitis Abscess formation . absorbed overs hours Benzanthine is absorbed over days.

renal failure. diarrhea. Enterobacter aerogenes. Staphylococci. aeruginosa First Generation Cephalosporins Adverse Effects GI Signs and Symptoms N & V. Non-enterococcal streptococci Minor activity against gram (-) bacteria. Neisseria species 3rd Weak against gram + bacteria but are more potent against gram (-) bacilli HENPEcKs –Serratia marcescens 4th Active against gram (-) and gram (+) organisms.Sodium overload - Potential fluid overload Hypertension CI: cardiovascular problems Cardiac arrhythmias • Monitor vital signs especially blood pressure Monitor serum electrolytes Monitor ECG and vital signs • • Potassium overload PENICILLINS Drug-Drug Interactions Tetracyline Effect and Significance Decrease effectiveness of Penicillin G Deactivated by Pen G Slows excretion of Pen G Longer t1/2 Prolongs bleeding Decreases plasma levels of contraceptive Impairs absorption of Pen G • Nursing Interventions Avoid combination therapy Aminoglycoside IV Probenecid PO - • • Administer 2 hours apart Beneficial reaction Anticoagulants Oral contraceptives • • Monitor for signs of bleeding Use up back up method of birth control Administer 1 hour before and 2 hours after meals Food - • CEPHALOSPORINS    Beta lactam antibiotics Similar to Penicillin in structure and activity (interferes with bacterial wall synthesis) Contraindicated for those allergic to penicillins (increased risk of cross sensitivity) .Haemophilus influenza. PEcK – Proteus mirabilis. Monitor hydration status Replace fluids lost • Skin test . pregnant and lactating women Four Generations of Cephalosporins Major Differences Activity against Gram (-) bacteria Resistance of Beta lactamase Ability to distribute in CSF 1st Least activity 2nd 3rd 4th Most activity - Little resistance poor - Less sensitive - Highly resistant - Most resistant - - poor - good - good Four Generations of Cephalosporins Spectrum of Activity 1st • • • • • Most active against gram + bacteria affected by Pen G. abdominal pain. coli. cephalosporin resistant Staphylococci and P. E. Klebsiella pneumoniae 2nd HENPEcK. flatulence Pseudomembranous colitis (bloody violent diarrhea) Nursing Intervention • • • - Taken with foods or fluid to decrease GI distress.

Hypersensitivity reaction - Rash. swollen glands. SOB. infuse over 30-45mins 24X/day Monitor vital signs. because it is too painful IV macrolides should be infused slowly to avoid painful phlebitis Gastric acid destroys erythromycin in the stomach. seizure. N & V. chest pains. dizziness. first introduced in 1952 Mechanism of Action: binds to the 50S ribosomal subunits and inhibits protein synthesis Route: Administered orally and IV but not IM. paresthesia Thrombophlebitis Abscess formation • IV site reaction - • • • • Inject IM preparations into large muscle mass. Interferes with Vitamin K metabolism Bleeding gums. neutropenia. clarithromycin. blurred vision. confusion. urine input and output monitor serum blood urea nitrogen and creatinine levels Serum sickness like reaction Nephrotoxicity - Fever. stearate. ethylsuccinate. severe infections or in immunocompromised patients Active against P.        . hives. palpitations. edema oliguria Second Generation Cephalosporins Adverse Effects Thrombocytopenia Bleeding Signs and Symptoms Decrease Prothrombin levels “Warfarin –like “ and antiplatelet activity. WBC. acid resistant salts are added (e.g. lethargy. faintness. unconsciousness Third Generation Cephalosporins • • Avoid alcohol for 72 hours after completing drug therapy Educate patient about hidden sources of alcohol like OTC cough and cold remedies    Indicated for bacterial strains resistant to aminoglycosides. sweating. urticaria. dizziness. azithromycin Broad spectrum antibiotics characterized by molecules made up of large ring lactones Derived from fungus-like bacteria Streptomyces erythreus. respiratory depression. aeruginosa Ceftriaxone is the drug of choice for Gonorrhea Induces bleeding tendencies like 2nd generation cephalosporins  CEPHALOSPORINS Drug-Drug Interactions Effect and Significance Nursing Interventions Anticoagulant - Prolonged bleeding • Monitor for signs of bleeding Aminoglycosides - Increased risk of nephrotoxicity • Avoid coadministration Probenecid - Prolongs effect of antibiotic • Beneficial reaction MACROLIDES  Used as penicillin substitutes for a clients allergic to penicillin Examples: Erythromycin. Obsserve sterile technique IV: dilute with IV fluids. anaphylaxis • • Monitor vital signs first 30 mins after IV administration Epinephrine and Respiratory support must be available Safety precautions CNS - Headache. arthralgia.. bruised skin • • • • Nursing Intervention Advise patient about signs and symptoms of bleeding Adjust dosage of anticoagulants Have Vitamin K available Avoid aspirin and NSAIDS - “Disulfiram-like” reaction - Inhibits enzyme alcohol dehydrogenase (Antabuse) Flushing.

abdominal cramps or tenderness Stool examination for WBC. neonates Nursing Interventions        Adverse Reactions of Lincosamides N & V. infuse over 30 to 60 mins Dilute drug with normal saline or D5W Apply cold compress if pain persist Reconstitute with sterile water and observe aseptic techniques IV infusion rate should not be > 15mg/min Monitor vital signs and ECG findings N &V. erythema. sore throat Monitor CBC Superinfection: Antibiotic associated colitis “Pseudomembranous colitis” or Clostridium difficile colitis Hypersensitivity reaction Blood dyscrasia . clarithromycin and azithromycin Adverse Reaction of Macrolides Allergic reaction - Nursing Intervention Epinephrine. hepatic/renal dysfunction. pregnancy. very toxic drugs Mechanism of Action: Inhibits protein synthesis Route: Oral. aspartate aminotransferase) and jaundice (bilirubin levels) Safety precautions Tinnitus. skin and soft tissue.administer azithromycin 1 hr before and 2 hrs after meals with a full glass of water IV administration irritating to veins.estolate) –Acid resistant macrolides      Elimination: via bile and feces. Burning sensation at the IV injection site Abscess formation QT interval prolongation Ventricular tachycardia Hepatoxicity (large doses of azithromycin) - - Monitor for elevated liver enzymes (alkaline phosphatase. STDs Drug of choice: Mycoplasma pneumonia and Legionnaire’s disease Extended macrolide group: longer t1/2 and administered once a day. Acute hematogenous osteomyelitis. NOTE: Renal insufficiency is not a contraindication Spectrum of activity: active against gram (+) bacteria. GIT. abdominal pain. blood and mucus Replace fluid lost. IV. sinuses. monitor hydration status Assess for reaction to drugs with “mycin” or “micin” Monitor for rash. less effective against gram (-) bacteria Uses: Respiratory tract infections. antihistamine available Prepare for respiratory support Small frequent meals Replace fluids lost Oral. opthalmic Elimination: metabolized in liver. Topical forms: acne vulgaris and bacterial vaginosis Contraindications: Allergy ot lincosamide and tartrazine (component of some clindamycin). Diarrhea. anaerobic gram (+) and (-) microbes Uses: Septicemia. anaphylactoid reaction Monitor for signs of fever. abdominal pain (PO) - Administer on anempty stomach with a full glass of water Give with small meals if there is GI upset Monitor for signs of diarhea. bronchodilators. IM. diphtheria. Topical. alanine aminotransferase. itchiness. reversible hearing loss Drug – Drug Interactions • • • • • • • • • Digoxin Warfarin SSRI Theophylline Clozapine Ca channel blockers Benzodiazepine Pimozide Acetomenophen - - Effect and Significance (Macrolides) Inhibits metabolism of many drugs increasing their serum concentration Increased risk of adverse effects and toxic reactions Sudden cardiac death QT interval prolongation Additive hepatotoxic effect LINCOSAMIDES  Used as penicillin substitutes for a clients allergic to penicillin Examples: Clindamycin (Cleocin) and lincomycin (Lincocin). history of colitis. excreted in bile and urine Spectrum of Activity: life threatening infections caused by aerobic gram (+) cocci. Pseudomembranous colitis - Phleitis.

inflammatory bowel disease Adverse Reactions to Vancomycin Nursing Interventions Ototoxicity - Tinnitus. a toxic and not an allergic reaction Hypotension. (IV) Methicillin resistant staphylococcus aureus Contraindications: Elderly due to age related decrease in renal function. vertigo.Dryness of skin (xeroderma) Dryness of conjunctiva (xeropththalmia) Dryness of mucous membrane - Use of topical preparations Apply lotion for skin and artificial tear for eyes Suck sugarless candy L I N C O SA M I D E S Drug-Drug Interactions Neuromusclar Blockers Effect and Significance Potentiates its action Nursing Interventions • • Mark “Warning” on chart Extended monitoring and support after surgery Avoid coadministration Erythromycin Chloramphenicol Opiates Aluminum salts or Kaolin Pyrimethanine - Antagonizes effect of clindamycin • - Enhances its effect. Lower dosage Nephrotoxicity - “Red Man” or “Red Neck” Syndrome Red blotching of the face. tachycardia. generalized tingling (paresthesia) Administer IV dose over 60 minutes Use large vein and administer slowly IV injection site reaction Thrombophlebitis Leukopenia. neck and chest due to histamine release. Kidney function test. Thrombocytopenia - Periodic CBC testing for prolonged use. infuse IV slowly Avoid coadministration of other ototoxic drugs Monitor I & O. not absorbed systemically but excreted in the feces. nystagmus (vestibular) Periodic audiometric testing Keep serum levels < 60 to 80ug/ml Lower dosage. respiratory depression Decreases GI absorption of clindamycin • • Monitor respiration Administer 2 hrs before and 3-4 hrs after oral clindamycin dose Beneficial reaction - Synergistic effect in treating toxopasmic encephalitis in patients with AIDS • VANCOMYCIN       A complex and unusual tricyclic glycopeptide Mechanism of Action: inhibits cell wall synthesis Route: oral administration limited to treating GI infections. blood monitoring VANCOMYCIN Drug-Drug Interactions Antihyperlipidemic (Statins) Nephrotoxic drugs - Effect and Significance ↓ effectiveness of vancomycin Additive risk • • • • • Nursing Interventions Separate administration by 3-4 hrs Lower dosage of vancomycin Monitor renal function Monitor hearing function Avoid combination DESIRED OUTCOME Ototoxic drugs Nondepolarizing muscle relaxants NURSING DIAGNOSIS VANCOMYCIN - Additive risk Additive blockade - . not absorbed systemically: generally given IV for severe infections due to MRSA. septicemia Elimination: mainly feces Uses: (PO) antibiotic associated Peudomembranous colitis due to Clostridum difficile. hypersensitivity. pregnancy. hearing loss (cochlear) Ataxia. N & V.

methacycline Mechanism of Action: Act by inhibiting bacterial protein synthesis Route: Oral. Known allergy to tetracycline or to tartrazine. Malaria prophylaxis. Mycoplasma pneumaniae. as part of combination therapy to eliminate H. treatment of Anthrax (Doxycyclline). Mg and Al salts. Renal or hepatic dysfunction: Non-bacterial ocular infection       Adverse Reactions to Tetracyclines N & V. diarrhea Discoloration and mottling of teeth Photosensitivity (Sun burn reaction) - Nursing Interventions Small frequent meals Increase fluid intake Should not be taken by pregnant women and children younger than 8 years old Avoid direct sunlight. Dairy products. remain indoors Use sunscreen with SPF >15. Chlamydia.prophylactic for opthalmia neonatorum (Neisseria gonorrhea): Topical preparations for acne vulgaris and periodontal disease: IV route is used for treating severe infections: IM route seldom used because it causes pain and tissue irritation Elimination: primarily excreted in the urine Uses: Rickettsiae. Acne. drug of choice to stage 1 Lyme disease Contraindication: Pregnancy. pylori infections. Syphilis. stomatitis - Signs of Superinfection from the drug Effective oral hygiene several times a day Suck on ice chips or sugarless candy Light and heat decomposes TCN Expired TCN is toxic Becomes nephrotoxic ( T C Ns ) Nursing Interventions • • • • Avoid combination Use additional form of birth control Separate administration by 3-4 hrs Administer 1 hr before or 2 hrs after meals Monitor blood glucose Toxicity from Decomposed TCN - TETRACYCLINES Drug-Drug Interactions Penicillin G Oral contraceptive Antacids containing Ca. Iron preparations Insulin Digoxin Anticoagulant - Effect and Significance ↓ effectiveness of Pen G Less effective - - ↓ absorption of TCN - ↑ hypoglycemia ↓ Metabolism of digoxin by GIT TCN eliminates Vit K Increases activity of anticoagulant • • • Monitor digoxin levels and toxicity Monitor for signs of bleeding AMINOGLYCOSIDES  Powerful antibiotics used to treat serious infections caused by gram (-) aerobic bacilli . children younger than 8 yrs. chronic Periodontitis. breastfeeding.• • • • Risk for injury R/T drug induced histamine release reactions Disturbed sensory perception (auditory) r/t drug induced ototoxicity Fluid excess volume r/t nephrotoxicity from drug therapy Risk of infection r/t overgrowth of non-susceptible organisms     The patient will experience no preventable reaction r/t vancomycin The patient will report any unusual auditory sensations and have periodic audiograms to detect ototoxicity The patient will remain normovolemic throughout the therapy The patient will report signs and symptoms of superinfection ot the prescriber ( T C Ns ) TETRACYCLINES     Isolated from Streptomyces aureofaciens in 1948 A semisynthtic antibiotic based on the structure of a common soil mold A broad spectrum antibiotic that affects both gram (+) and gram (-) bacteria They have a 4 ring structure Examples: doxycycline. Opthalmic. cover up with clothing Monitor liver and renal function test (azotemia) Nephrotoxicity / Hepatotoxicity - Sore mouth and throat. most common and 100% absorbed. Gonorrhea. minocycline.

Topical. Parkinson’ s. Ophthalmic. cast. pruritus. proteinuria. hypotension. ↓ CREA clearance. ↓Mg) • • • • • • Hearing loss. numbness. pyuria (↑ WBC) Electrolyte imbalance ( ↓K. IM Use / Significance • • Pseudomonas infection and a wide variety of gram (-) infections IV. weight loss Blood dyscrasia • • • • Small frequent meals Monitor CBC and for signs of anemia CNS effect Cardiovascular Confusion. Tinnitus. primarily administered IM or IV. pholtosensitivity • • • • Antihistamines Sunblock Monitor vital signs Drink lots of water . Stomatitis (mouth ulcers) Genital ulcers (vaginitis) Anal and genital itching • . IM) Contraindication: Hepatic / Renal dysfunction. Ototoxic and Nephrotoxic AMINOGLYCOSIDES Adverse Effects • • Nephrotoxicity • Signs and Symptoms Diminished urinary excretion Azotemia (urea in blood). Liposomal injections Elimination: Urine (IV. balance problems Persistent headache Dizziness. Concomitant use of succinylcholine GIT effect Bone marrow depression • • • N & V. dilute in 50-200ml of normal saline of D5W solution and administer over 30-60 mins Meningitis Chronic Osteomyelitis Gentamycin • • • • • Intrathecal Impregnated beads on surgical wire Liposomal injections Ophthalmic Topical • • • • • • • • Skin wounds of infection Kanamycin • • • Oral To reduce normal GI flora (7-10) days only To reduce ammonia forming bacteria in hepatic coma Suppression of GIT flora preoperatively Treatment of hepatic coma Skin ifections Ocular infections Respiratory infection Neomycin Oral but not absorbed systemically from the GIT OTC Topical Tobramycin • • • Ophthalmic form For nebulization Oral • • Streptomycin • 4th drug in combination therapy for Tuberculosis. depression.  Ineffective against Aneorobes (Gentamicin must be transported across the membrane in order to enter the cell and disrupt protein synthesis-this requires oxygen) It is poorly absorbed in the gastrointestinal tract Mechanism of Action: inhibits protein synthesis Route: Oral. hypertension • Monitor vital signs Hypersensitivity Rash. blood cells Monitor BUN & CREA Careful dosing especially for younger and older clients Therapeutic drug monitoring CI: hearing problems Safety measures Avoid concomitant use of other ototoxic drugs Ototoxicity • • Neuromuscular blockade • • Profound Respiratory depression Warning on chart for preoperative patients • CI: Myasthenia gravis. pregnant and lactating women     Aminoglycoside Amikacin • Route/ Dosage Forms IV. tingling or weakness Safety precautions • • • Palpitaions. Mouth care Antifungal medication Superinfections • • • Fever. diarrhea. vertigo • • • Nursing Intervention Measure I & O Urinalysis – check for protein.

2. bile. delirium Rash. diarrhea. confusion. Neisseria meningitides or haemophilus influenzae Brain abscess Rickettsial infection Acute Typhoid fever (Outbreak) 5. pancytopenia. 9. children Hepatic/renal impairment Glucose 6 phosphate dehydrogenase deficiency (G6PD) Acute intermittent porphyria Anemia Patients with depressed marrow function (Cytotoxic drug and Radiation therapy) Dental disease with dental work. infants. monitor renal & hepatic function - “Reversible Bone Marrow Depression” Blood dyscrasia Aplastic anemia. infants. Active against gram (+) and gram (-) infections (anaerobic bacteria Meningitis caused by Streptococcus pneumoniae. pruritus. rapidly proliferating cells like erythrocytes Route: Oral: Chloramphenicol Base. Topical Distribution: Highest concentration in liver and kidney. dermatitis. CHLORAMPHENICOL Adverse Effects “Gray Baby Syndrome” -Life threatening Signs and Symptoms Failure to feed. Monitor CBC Keep plasma levels below 25ug/ml to decrease adverse hematogic reactions Monitor for signs of anemia and blood dyscrasia Monitor for signs Safety measures Small frequent meals Mouth care Fluid replacement Monitor for signs Administer Pyridoxine as prophylaxis Monitor for signs Safety measures Avoid rubbing. burning Topical use/Systemic effect - CHLORAMPHENICOL  Interference with hepatic metabolism and clearance of other drugs Effect and Significance ↑ risk of bleeding Clinical hypoglycaemia ↑ toxicity • • • Nursing Interventions Dosage adjustment Dosage adjustment Dosage adjustment Drug-Drug Interactions Oral anticoagulants Oral hypoglycemics Hydantoins . vasomotor collapse Nursing Intervention CI: premature infants and newborns Measure I & O. 3. 5. tight clothing. 2. 8. harsh soaps. NOTE: affects both bacterial and human cells. IV: Chroramphenicol succinate. Opthalmic. mild depression. 3. perfumed lotions Topical antihistamines or corticosteroids - Opthalmic effects - - GIT effects - N & V. vomiting. abdominal distension. In humans. Otic. 7. 4. relatively toxic and reserved for serious infections Mechanism of Action: Inhibits protein synthesis. enterocolitis Peripheral neuritis Neurotoxic effects - Vitamin B6 deficiency Headache. feces Indications / Uses Contraindication 1. nephrotoxicity and hepatotoxicity      1. once a week. premature baby) Burning and itching of the eyes Optic neuritis-blindness Monitor plasma levels.AMINOGLYCOSIDES Drug-Drug Interactions Penicillin Warfarin Ethacrynic acid (Loop diuretic) Effect and Significance Decreased effect of aminoglycoside Drug action of warfarin increased Increased ototoxicity • • • Nursing Interventions Given several hours apart Decrease dosage of warfarin Avoid coadministration CHLORAMPHENICOL   Isolated from Streptomyces venezuelae “1947” Broad spectrum antibiotic. stomatitis. substantial CSF concentrations in patients with inflamed meninges Elimination: Kidney. glossitis. 6. blue gray skin. myelosuppression Drugs that cause hematologic. Hypersensitivity to the drug Pregnant. thrombocytopenia Plasma levels of drug increase with renal and hepatic dysfunction (newborn. 4.

pregnant or lactating women. depression. eye. vomiting.penicillin. and joint infections. dizziness. ear. dry mouth Give with a full glass of water. diarrhea. erythromycin↑ - Altered bactericidal effects • Avoid concurrent administration FLUOROQUINOLONES  Synthetic antibacterials effective against aerobic gram (-) and gram (+) infections. children under 18 years old Four Generations of Fluoroquinolones       First Generation • • Cinoxacin Nalidixic acid - QUINOLONES Indicated for uncomplicated UTIs Second Generation • • • Lomefloxacin Norfloxacin Ofloxacin FLUOROQUINOLONES - Fluorine atom is added to the Quinolone structure Increased gram (-) and systemic activity Third Generation • • • • • Gatifloxacin Gemifloxacin Levofloxacin Moxifloxacin Sparfloxacin Extended activity against gram (+) pathogens Less active than 2nd generation fluoroquinolones against Pseudomonas species - Fourth Generation • • Alatrofloxacin Trovafloxacin - Same spectrum as 3rd generation fluoroquinolones Active against Pseudomonas species and anaerobic bacteria Signs and Symptoms Adverse Effects of Fluoroquinolones CNS effects - Headache. excreted in urine and feces Uses: It is indicated for respiratory. Alkaline phosphatase Decreased WBC and hematocrit Fluid intake should be > 2000ml/day Urine pH should be < 6. insomnia. may be taken with food if GI upset occurs Elevated BUN. flushing. cephalosporins.Iron salts - Iron overload and anemia ↓ iron clearance and erythropoesis • • • • Adjustment of iron dosage Monitoring of CBC Monitor Vit B12 response Consider alternative antibiotic Vitamin B12 - ↓ hematologic effects of Vit B12bin patients with pernicious anemia Antibiotics: Aminoglycosides. restlessness. AST (SGOT). Treatment after anthrax exposure and typhoid fever Contraindication: Known allergy. Mechanism of Action: Interferes with the function of DNA gyrase enzyme necessary for the growth and reproduction of bacteria Route: Oral. ALT (SGPT). Topical ophthalmic and otic preparations Elimination: metabolized in the liver. renal dysfunction.7 Monitor I & O. urinary tract. photosensitivity Joint disease that occurs in children under 18 yrs old Laboratory changes Crystalluria Tinnitus Dermatologic effects - - Arthropathy . dermatologic. Parenteral. CREA. the most widely used fluoroquinolones. Urine output should be at least 750 ml/day Monitor hearing ability Rash. These include urinary tract. respiratory and skin infections Ciprofloxacin. bone. flatulence. fatigue Avoid caffeinated products Avoid activities that require alertness Gastrointestinal effects - Nausea.

skin eruptions. itching Anaphylaxis is not common Anorexia.eye drops or ointment Indicated for conjunctivitis and corneal ulcers. coli. 3rd trimester pregnancy Classification according to their Duration of Action Short-acting Sulfonamide (Rapid absorption and excretion rate) • • • Sulfadiazine Sulfamethizole Sulfizoxazole (Gantrisin) Topical Sulfonamides • • • Intermediate-acting Sulfonamide (Slow absorption and excretion rate) Sulfamethoxazole Sulfasalazine Trimethoprim-sulfamethoxazole (Bactrim. Cream for burns Highly protein bound Elimination: Urine Uses: (1) Urinary tract infections. (3) Meningococcal meningitis.Tendon rupture IV site reaction Cartilage deterioration when administered to immature animals Report any tendon pain IV administration infused over 60 mins into a large vein FLUOROQUINOLONES Drug-Drug Interactions Antacid. aplastic anemia. Human do not synthesize folic acid. low WBC and platelet count Poor urine solubility Recommend increase fluid intake > 2000 ml/day Administer with a full glass of water 1hr before or 2 hours after meals Urine output should be at least 1200ml/day Excessive reaction to direct sunlight or UV light leading to redness and burning of skin Gastrointestinal disorders Blood disorders Crystalluria - Photosensitivity . (2) Against organisms like Chlamydia and Toxoplasma. prophylactic treatment after an eye surgery Adverse Reactions of Sulfonamides Allergic Reactions Signs and Symptoms - Skin rash.g.. iron salts Drugs that increase QT intervals (e. Ophthalmic: solution or ointment. Septra) Ophthalmic sulfonamides         • • • Mafenide acetate (Sulfamylon) – Creams for prevention of sepsis in 2nd or 3rd degree burns Silver sulfadiazine (Silvadine) Sulfacetamide sodium – skin ointment indicated for seborrheic dermatitis secondary bacterial infection • • Sulfacetamide sodium. phenothiazine) Theophylline NSAIDS Caffeine Hydantoins Oral contraceptives Effect and Significance ↓ absorption Fatal cardiac reaction • • • Nursing Interventions Separate administration by 4 hrs Cardiac monitoring Decrease dosage of theophylline Monitor for signs of CNS stimulation Check for history of seizure and CNS problems CNS stimulation and cardiovascular effects Dosage adjustment Backup birth control - ↑ theophylline toxicity ↑ CNS stimulation ↓ hepatic metabolism ↑ phenytoin concentration ↓ seizure activity Decrease effectiveness • • • • • SULFONAMIDES     One of the oldest antibacterial agents used to combat infection Isolated from a coal tar derivative compound in the early 1900s Clinically used against coccal infection in 1935 NOT classified as an antibiotic (Not obtained from a biologic substance) Not used alone but in combination with Trimethoprim Mechanism of Action: It inhibits the bacterial synthesis of Folic acid which is essential for bacterial growth. they derive it from their diet Route: Oral. Folic acid is required by cells for biosynthesis of RNA.well absorbed from GIT. (4) prophylaxis in clients with rheumatic fever who are allergic to penicillin Contraindication: Hypersensitivity to sulfonamides. DNA and proteins Selectively inhibits bacterial growth without affecting human cells. amiodarone. nausea and vomiting Haemolytic anemia. 90% effective against E. hepatic and renal disease. procaineamide.

AST. SEPTRA) C O T R I M O X A Z O LE          TRIMETHOPRIM (TMP) and SULFAMETHOXAZOLE (SMZ) combination Drug ratio: (1:5) TMP:SMZ. bactericidal Route: Oral and IV Elimination: Urine Uses: UTIs. vomiting. Lower respiratory tract infections. Streptococcus species Contraindication: Hypersensitivity to the drug       CYCLIC Adverse Effect Gastrointestinal L I P O P E P T I D E S .DAPTOMYCIN (CUBICIN) Signs and Symptoms • • Nursing Interventions Small frequent meals Monitor hydration status Avoid coadministration with Statin drugs (HMG-CoA) or stop during antibiotic therapy D/C if CK is 5-10X the upper limit Administer IV over 30 mins - Nausea and vomiting. ACTION: It interferes with bacterial folic acid synthesis just like sulphonamide Mechanism of Action: Inhibition of protein synthesis of nucleic acid. gonorrhea. administer over 30 mins without any other IV substances. CREA. ALP Adverse Reactions of Cotrimoxazole Gatrointestinal Secondary infection Rash Crystalluria Photosensitivity Blood dyscrasia - Signs / Symptoms and Nursing Interventions Anorexia. sun block. diarrhea Stomatitis. bacterial resistance develops more slowly Trimethoprim (TMP) is classified as a urinary tract anti-infective. hepatic and renal disease LAB test: ↑ BUN.Cross sensitivity Avoid sunbathing - Sensitivity to on sulphonamide may lead to sensitivity to another sulfonamide (BACTRIM. at 4-8 mg/kg/day Administration: with 0. Intestinal. Infective endocarditis due to MRSA. dyspepsia Rhabdomyolysis Myopathy Myalgia (muscle cramps or pain) Muscle weakness (fatigue) Numbness and tingling • • - • (↓↑ • • Metabolic disturbances - Electrolyte imbalance Renal and liver function test Monitor Metabolic panel . Pneumocystis carinii (clients with AIDS) Contraindication: Hypersensitivity to sulfonamides. nausea. otitis media. haemolytic anemia (BACTRIM. vaginitis Topical antihistamines Increase fluid intake not > 200ml/day Use sunglass.9% NaCl or Lactated Ringer’s solution. prostatitis. aureus. diarrhea. synergistic effect. SEPTRA) Nursing Interventions • • • Dosage adjustment Monitor for signs of bleeding Allow 4 hr interval - - C O T R I M O X A Z O LE Drug-Drug Interactions Sulfonylureas Warfarin Antacid - Effect and Significance ↑ hypoglycemic response ↑ anticoagulant activity Decreased absorption CYCLIC L I P O P E P T I D E S – D A P T O M Y C I N ( CUBICIN )     Reserved for infections that do not respond to other antibiotics It has the ability to retain potency against antibiotic-resistant gram positive bacteria There is no known transferable element (plasmids) that can confer resistance No known report of cross-resistance Mechanism of Action: Interferes with the integrity of the cell wall Route: IV once daily. NOT compatible with Dextrose solution Elimination: Urine Uses: Serious aerobic gram (+) complicated skin and skin structure infection caused by Enterococcus feacales. protective clothing Life threatening agranulocytosis. maybe used alone for uncomplicatied UTIs and affects gram negative bacteria. S. ALT.

Tryptophan Effect and Significance Hypertensive crisis • • • • Nursing Interventions Avoid coadministration Do not administer linezolid 14 days after these drugs Monitor BP Avoid OTC drugs - May cause serotonin syndrome STREPTOGRAMINS QUINUPRISTIN / DALFOPRISTIN (SYNERCID)     Designed to eradicate “Super bugs” resistant to other antibiotics Mechanism of Action: Inhibits bacterial protein synthesis Route: IV only. bleeding • • Monitor CBC CNS effects - Headache. ↑ Bicarbonate) Hyperglycemia Elevation of Creatinine Kinase. OTC drugs Elevated liver enzymes. obtain liver function test Bone marrow depression Hypertension Hepatic O X A Z O L I D I N O N E S – L I N E Z O L I D ( ZYVOX) Drug-Drug Interactions MAO Inhibitors Levodopa SSRI Sympathomimetics Tyrosine. hyperthyroidism. vomiting. pheochromocytoma Monitor intake of tyramine rich foods. hypertension. Skin infections. diarrhea Pseudomembranous colitis Blood dyscrasia (e. both 100% bioavailable. 2. phenylketonuria ( oral suspension has 20 mg phenylalanine/5ml). Should be diluted with 250 ml of D5W and infused over one hour DO NOT FLUSH the IV line with saline or heparin (NOT compatible).Laboratory results - K. thrombocytopenia) Drug induced MAO inhibition Monitor blood pressure Contraindicated in clients with HPN. hepatic enzymes. 4. alkaline phosphatase and INR • Monitor blood glucose • • Obtain baseline CK Weekly CK monitoring (myopathy) Avoid warfarin • Blood dyscrasia Anemia.1 hr Administration Precautions: 1.g. blood dyscrasia   Adverse Effect of Linezolid Gastrointestinal - Signs/Symptoms and Nursing Intervention Nausea. alcohol.. Onset rapid: half life. swelling Phlebitis Edema Infiltration - • • • Nursing Interventions Monitor for signs Ask patient regarding pain at the injection site Administer through PICC or central line when possible . insomnia Safety precautions O X A Z O L I D I N O N E S – L I N E Z O L I D ( ZYVOX )     Developed specifically for treating MRSA Mechanism of Action: Inhibits protein synthesis Route: Oral and IV. 3. dizziness. and penicillinsusceptible Streptococcus pneumonia. caffeine. Nosocomial and community acquired pneumonia Contraindication: hypersensitivity to drug. ↓ Mg. MRSA. both forms interchangeable without dosage adjustment Elimination: Uses: Infection/Bacteremia caused by Vancomycin resistant Enterococcus faecalis (VRE). flush line with D5W Should not be administered with Y-site infusion unless compatibility of drug and diluent is established Administer through Peripherally inserted central catheter (PICC) or central line if possible    Elimination: converted to several major active metabolites and excreted primarily through bile Uses: for VRE bacteremia and for complicated skin and skin structure infections due to Staphylococcus aureus Contraindication: hypersensitivity and decreased hepatic function Adverse Effect of Synercid Injection Site Reactions - Signs and Symptoms Pain.

perfumed lotions Topical antihistamines or corticosteroids Gastrointestinal effects - Nausea. vomiting. pruritus - QUINUPRISTIN / DALFOPRISTIN (SYNERCID)     Drug-Drug Interaction: Potent inhibitor of cytochrome P 450 liver enzymes Serum concentration of drugs metabolized through this pathway maybe increased Avoid coadministration of drug if possible Monitor for toxicity if coadministration is unavoidable . Monitor hydration status Replace fluids lost Report Avoid rubbing. tight clothing. diarrhea Pseudomembranous colitis Musculoskeletal effects Dermatologic effect - Arthralgina. myalgia Rash. bilirubin test Taken with foods or fluid to decrease GI distress.Hepatotoxicity - Hyperbilirubinemia • • • • • • • • • Asses history of liver dysfunction Monitor for signs and symptoms Liver function test. harsh soaps.

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