Macrolides: - Nephrotoxicity (renal failure)

- Ototoxicity ( auditory impairment and vestibular

Side Effects
[eighth cranial nerve)
- GI EFFECTS, primarily with, erythromycin
• Must monitor drug levels to prevent toxicities
- nausea, vomiting, diarrhea, hepatotoxicity,
flatulence, jaundice, anorexia - Creatinine level
- Newer agents, azithromycin and clarithromycin: - URINE OUTPUT
fewer side effects, longer duration of action, better - BUN
efficacy, bétter tissue penetration
Aminoglycosides: Side Effects
Ototoxicity and nephrotoxicity are the most Significant:
OXAZOLIDINONE
 Headache
Linezolid (Zyvox)  Paresthesia
 Neuromuscular blockade
- oxazolidinone antibiotic that can work on both methicillin-
 Dizziness
resistant Staphylococcus aureus(MRSA) and vancomycin-
 Vertigo
resistant enterococci (VRE)
 Tinnitus
 Skin rash
IV. ANTIBIOTICS - PROTEIN SYNTHESIS INHIBITORS -  Fever
BACTERICIDAL  Superinfections
- Bactericidal aminoglycosides can cause nephrotoxicity and
ototoxicity
V. ANTIBIOTICS FOR URINARY TRACT INFECTIONS (UTIS)
Amikacin (Amikin) — sepsis,
AND PEPTIC ULCER DISEASE (PUD)
Multidrug - Resistant TB (MDR TB)
Gentamicin (Garamycin) DIHYDROFOLATE REDUCTASE INHIBITORS
- affects the folic acid in bacteria; bacteria needs to synthesize
Antibiotics: Aminoglycosides folic acid whereas humans can get FA from food sources
•gentamicin (Garamycin)
• kanamycin Sulfamethoxazole / trimethoprim [Co-trimoxazole] (Bactrim)
• neomycin - Combination of trimethoprim and sulfamethoxazole
• streptomycin - Sulfa clears UTI; used as prophylaxis for
•tobramycin immunocompromised patients
•amikacln (Amikin) - Sulfa may cause Stevens-Johnson syndrome
• netilmicin
Antibacterial: Sulfonamides---1935
Aminoglycosides - One of the oldest antibacterial agent
- Isolated from coal tar derivative
• Natural and semi-synthetic - Not classified as an antibiotic
• Poor-oral-absorption; no PO forms
Mechanism of Action:
• Very potent antibiotics with serious toxicities • Bacteriostatic action
• Bactericidal • Prevent synthesis of folic acid required for synthesis of
• Kill mostly gram-negative; some gram-positive also proteins and nucleic acid
• Used to kill gram-negative bacteria such as: Pseudomonas • Does not affect human cells or certain bacteria— they can
spp., E. coli, Proteus spp., Klebsiella spp., Serratia spp. use preformed folic acid
• Often used in combination with other antibiotics for
synergistic effect. Sulfonamides : Therapeutic Uses
• UT I'søcaused by Escherichia Coli
Aminoglycosides • Ear infections
• Meningococcal meningitis
• Three most common (systemic): gentamicin, tobramycin, • Chlamydia and Toxoplasma gondii
amikacin Note: not effective against viruses and fungi
• Cause serious toxicities:
Sulfonamides: kinetics  Carbamazepine
• Well absorbed in the Gl  Nevirapine
• LIVER metabolizes
• KIDNEY excrete General Points

 HIV-I patients are 1,000 times more likely to develop

Sulfonamides: dynamics SJS/TEN compared to the general population.
• Available for oral, in solution, ointment and cream form  Those who survive acute phase are likely to suffer
• Highly protein bound long-term ocular complications.

CommoN Drugs:
• sulfacetamide (silver sulfadiazine) Antibiotics: Quinolones
 Burns and wounds
•ciprofloxacin (Cipro)
 Poorly soluble in urine • enoxacin (Penetrex)
• sulfamethizole •lomefloxacin (Maxaquin)
• sulfamethoxazole • norfloxacin (Noroxin)
• Sulfisoxazole—water soluble •ofloxacin (Floxin)
• TRISULFAPYRAMlDlNES=sulfadiazine, - methazine-merazine

SULFANAMIDES- UTI MEDS ANTI - INEFECTIVE DWG

-Stops folic acid synthesis and non pregnancy safe
• S - SUNBURN (SUNBLOCK AND AVOID SUN) mntrd
• U — urine (crystals and
O
• L- LOVE ( water- 2-3 L)
• F— Folic acid (Take daily) Quinolones
• Excellent oral absorption
• Absorption reduced by antacids
Stevens-Johnson Syndrome & Toxic Epidermal Necrolysis • First oral antibiotics effective against gram-negative
bacteria
 SJS and TEN are rare, life-threatening dermatological
conditions that result when the epidermis becomes
detached from the dermis, leaving the body Quinolones: Mechanism of Action
susceptible to infection. • Bactericidal
• Effective against gram-negative organisms and some gram-
 It is termed SJS when of the body is affected,
positive organisms
SJS/TEN when 10-30% is affected, and TEN when
•Alter DNA of bacteria causing death
greater than 30% of body surface area is affected.
•Do not affect death human DNA
 The mortality rate of TEN is 25-30%. Its severity is
measured using the Severity of Illness Score for Toxic
Quinolones: Therapeutic Uses
Epidermal Necrolysis (SCORTEN).
• Lower respiratory tract infections
Treatment Options: • Bone (ex.A.N.) and joint infections
• Infectious diarrhea
 Discontinuing Causative Factor • Urinary tract infections
 Supportive Management • Skin infections
 Nutritional Support • Sexually transmitted infections (ST I's)
Commonly Implicated Drugs :
Quinolones: Side Effects
 Sulfonamides
 Penicillins Body System Effects
 Allopurinol
CNS headache, depression, restlessness
 Phenytoin
 Valproic Acid
GI nausea, vomiting, diarrhea,
 Cephalosporins constipation, thrush, increased liver
 NSAlDs function studies
 Methotrexate
 Integumentary Rash, pruritus, urticaria, flushing,
photosensitivity (with lomefloxacin)
Other Fever chills, blurred vision, tinnitus
• Be sure to obtain thorough patient health history, including
immune status.
• Assess for conditions that may be contraindications to
antibiotic use, or that may indicate cautious use.

• Assess for potential drug interactions.

FLUOROQUINOLONES
• Patients should be instructed to take antibiotics exactly as
- like tetracyclines, photosensitivity and chelation
prescribed and for the length of time prescribed; they should
- Often used for genitourinary infections
not stop taking the medication early when they feel better.
- Can be given an empty stomach and with full glass of H20
- very unusual, rare side effect: tendon rupture • Assess for signs and symptoms of Superinfection: fever,
perineal itching, cough, lethargy, or any unusual discharge.
Ciprofloxacin (Cipro)
Levofloxacin (Levaquin) • For safety reasons, check the name of the medication
carefully since there are many agents that sound alike or have
similar spellings.
Antibiotics: Macrolides
• Each class of antibiotics has specific side effects and drug
• erythromycin (Erythrocin, Mylan)
interactions that must be carefully assessed and monitored.
• azi thromycin (Zithromax)
• clarithromycin (Biaxin) • The most common side effects of antibiotics are nausea,
• dirithromycin (Dynabac) vomiting, and diarrhea.
• troleandomycin (Triocetin)
- BACTERICIDAL ACTION • All oral antibiotics are absorbed better if taken with at least
6 to 8 ounces of water.
Macrolides: Therapeutic Uses Antibiotics: Nursing Implications
Strep infections
 Streptococcus pyogenes (group A beta-hemolytic  Sulfonamides
streptococci) - Should be taken with at least 2400 mL of fluid per
Mild to moderate URI day, unless contraindicated.
 Haemophilus influenzae - Due to photosensitivity, avoid sunlight and tanning
Spirochetal infections beds.
 Syphilis and Lyme disease - These agents reduce the effectiveness of oral
Gonorrhea, Chlamydia, Mycoplasma contraceptives.

NITROIMIDAZOLE
Metronidazole (Flagyl)
- for peptic ulcer disease (PUD)
- Amoebiasis (anti-protozoal)
- Inhibit DNA synthesis in susceptible protozoa, interfering
with the cells, ability to reproduce, subsequently leading to
cell death
- Notable side effect is GI UPSET — nausea and vomiting
triggered by alcohol- containing substances
METRONIDAZOLE
M — metallic taste and dark urine (normal)
•E — ETOH — avoid alcohol
•T - Treats C Diff and STI (Trichomoniasis)
• R — Rash or skin peeling (Report) -
•O— OH NOT "Dazole" ing
Antibiotics: Nursing Implications
• Before beginning therapy, assess drug allergies; hepatic,
liver, and cardiac function; and other lab studies.
 Penicillin
- Any patient taking a penicillin should be carefully
monitored for an allergic reaction for at least 30
minutes after its administration.
- The effectiveness of oral penicillin’s is decreased
when taken with caffeine, citrus fruit, cola
beverages, fruit juices, or tomato juice.
 Cephalosporins
- Orally administered forms should be given with
food to decrease Gl upset, even though this will
delay absorption.
- Some of these agents may cause an Antabuse-like
reaction when taken with alcohol.
 Tetracyclines
- Milk products, iron preparations, antacids, and
other dairy products should be avoided because of
the chelation and drug-binding that occurs.
- All medications should be taken with 6 to 8 ounces
of fluid, preferably water.
 - Due to photosensitivity, avoid sunlight and tanning
beds.
 Aminoglycosides
- Monitor peak and trough blood levels of these
agents to prevent nephrotoxicity and ototoxicity.
- Symptoms of ototoxicity include: dizziness, tinnitus,
and hearing loss.
- Symptoms of nephrotoxicity include: urinary casts,
proteinuria, and increased BUN and serum
creatinine levels.
 Quinolones
-Should be taken with at lest 3L of fluid per day
unless otherwise specified
- SE: bone marrow suppression, nephrotoxicity, hepatoxicity
Fluconazole (Diflucan)
- orally treats vaiinal yeast infections
Nystatin (Mycostatin)
- is used to treat fungal infections of the inside of the mouth
and lining of the stomach and intestines. Nystatin is in a class
of antifungal medications called polyenes. It works by
stopping the growth of fungi that cause infection.
- Not an HMG-CoA reductase inhibitors ("vastatin")
- Used for mycoses (fungal infectibns)
- Taken as "swish and spit" or "swish and swallow"

Monitor for therapeutic effects:

 Disappearance of fever, lethargy, drainage and

redness

VI. ANTI-TUBERCULOSIS AGENTS

- Used for an extended period (several months 6-12 mo)
because tuberculosis organisms grow slowly
- Hepatoxicity (jaundice and Inc ALST/AST)
- Test sgould be taken every 2-4 weeks
- After 3 negative sputum cultures - cured

Rifampin (Rifadin)
- turns secretions like tears, sweat, and urine red
Understanding Viruses
Isoniazid (INH) [isonicotinylhydrazide]
They are different from other Microbes
- peripheral neuritis, degease absorption of vit. B6
Virus Replication
Pyrazinamide (PZA)
• A virus cannot replicate on its own.
- Polyarthritis
• It must attach to and enter a host cell.
Ethambutol (Myambutol)
• It then uses the host cell's energy to synthesize protein,
- eye optic neuritis
DNA, and RM.
-Viruses are difficult to kill because they live inside the cells
ANTIFUNGAL AGENTS - any drug that kills a virus may also kill cells
- An infection caused by fungus called MYCOSIS, has rigid cell
Antivirals
wall (composition of the protective layers) that is why this
- available for many viral infections
organism is resistant to antibiotics
- Viruses controlled by current antiviral therapy
- Fungicidal and fungistatic effect
• Cytomegalovirus (CMV)
- Gl UPSET and HEAPATOXICITY (monitor liver function)
• Hepatitis viruses
• Herpes viruses
VI'. ANTIFUNGALS
• Human immunodeficiency virus (HIV)
• Influenza viruses (the "flu")
Two general types:
• Respiratory syncytial virus (RSV)
- systemic and dermatologic/topical
Amphotericin B (Fungizone)
Anti-viral drugs
- Because "A" didn't do anything
• Viruses have no cell wall and made up of nucleic acid
- can treat systemic infections
components
- IV
• Viruses containing envelope — Antigenic in nature (capable > Release
of triggering a rxn)
• Viruses are obligate intercellular parasite
• They do not have metabolic machinery of their own uses
host enzymes
• Certain viruses multiply in the cytoplasm but others do in
the nucleus
• Most multiplication take place before diagnosis is made.

Antivirals how they act

Key characteristics of antiviral dru5
• Able to enter the cells infected with virus
• Interfere with viral nüceic acid synthesis and/or regulation
• Sone drugs interfere with ability of virus to bind to cells
• Some drugs stimulate the body's immune system
• Best responses to antiviral drugs are in patients with
VIII. ANTIVIRALS - NON-HIV
competent immune systems
- Many antivirals have "-vir-" in the middle or at the end of
• A healthy immune system works synergistically with the
the generic and / or brand name
drug to eliminate or suppress Viral activity

INFLUENZA A and B
Antiviral Medications
Oseltamivir (Tamiflu)
• Antiviral drugs
- work when taken within 48 hours of the infection
- Used to treat infections caused by viruses other than HIV
- Family members of the patient may also need prescription
• Antiretroviral drugs
- prescribed for acute influenza or prophylaxis
- Used to treat infections caused by HIV, the virus that causes
ADS
Zanamivir (Relenza)
Herpes-Simplex Viruses
- work when taken within 48 hours of the infection
-HSV-I (oral herpes)
=HSV-2 (genital herpes)
HERPES SIMPLEX VIRUS & VARICELLA-ZOSTER VIRUS
Varicella Zoster Virus (HSV/VZV)
- Chid«enpox
- Shingles Acyclovir (Zovirax)
- acyclovir and valacyclovir can help prevent recurrences and
Anti-viral drugs treat an infection, but they do not cure the disease.
Stages of Viral Replication - 200 mg PO q4hr while awake (5 times daily) for 10 days or
> Cell Entry — Attachment - Penetration 400 mg PO q8hr for 7-10 days
> Uncoating
> Transcription of Viral Genome Valacyclovir (Valtrex)
> Translation - a pro drug, turns into acyclovir in the body
> Assembly of virion components - Given BID

RESPIRATORY SYNCYTIAL VIRUS (RSV)

- Common in children
Palivizumab (Synagis)
- “P” for pediatrics
"-vi-" antiviral (the target)
"-zu-" stands for humanized (the source),
"—mab" is for monoclonal antibody

VIII. ANTIVIRALS – HIV

 How HIV attacks human Medication Class
FUSION INHIBITOR cell:
Enfuvirtide (Fuzeon) (T-20) 1.HIV virus tries to fuse with 1.Fusion inhibitor
- "fu", "Fuzeon" — Fusion inhibitor the cell
2.Uses cellular chemokine 2.Cellular Chemokine
CELLULAR CHEMOKINE RECEPTOR (CCR5) ANTAGONIST receptor five (CCRS) Receptor (CCRS) Antagonist
Maraviroc(Seizentry) (MVC) 3.Uses reverse transcriptase 3.Reverse Transcriptase
- C in "viroc" for "CCR5" 4.Integrase 4.Integrase Strand Transfer
5.Protease 5.Protease Inhibitor
NON-NUCLEOSIDE REVERSE RANSCRIPTASE INHIBITORS - Inhibits hep C protease formation preventing viral
(NNRTI’S) WITH 2 NUCLEOSIDE/ NUCLEOTIDE REVERSE
TRANSCRIPTASE INHIBITORS (NRTI’s)

Efavirenz/Emitricitabine/Tenofovir (Atripla)
(EFV/FTC/TDF)
- “Aripla” -triple against AIDS
*Do not take with food.
*i.e. separate Dinner and drug
Viru Disease Drugs of Alternative
INTEGRASE STRAND TRANSFER INHIBITOR s choice drugs
Raltegravir (Isentress) (RAL) FLU Influenza Amantadin Rimatadine
Ral "-tegra-" vir — Integras_e e
RSV Pneumonia, Palivizumab
bronchiolitis Ribavin
PROTEASE INHIBITOR
(aerosol)
Darunavir (Prezista) (DRV) HSV Genital herpes Acydovir Foscamet
Keratits Conjunctivitis Trifluridine Idoxuride
Vidarabine
Encephalitis Acydovir
Neonatal HSV Acydovir Vidarabine
infection
Herpes infections in Acydovir Foscamet
immunocompromised
host
VZV In normal host No therapy
Immunocompromise Acydovir Foscamet
d host, or during
pregnancy
CMV Retinitis Gancidovir Foscamet
HIV AIDS. HIV antibody Zidovudine Didanosine,
positive with CD4 +/- Stavudine
count <500/mm3 protease
inhibitors
HBV Hepatitis B,C Interferons
ANTI HEPATITIS AGENTS
HCV

• Hepatitis B
- Is a serious to potentially fatal viral infection of the liver and
persistent elevation in serum aminotransferase
- Ex: ADEFOVIR, ENTECAVIR, TELBIVUDINE
- Inhibit reverse transcriptase in the hep B virus and cause
DNA chain termination, leadingto blocked viral replication
and decreased viral load.

• Hepatitis C
- Ex. BOCEPREVIR, SEMIPREVIR, SOFOSBUVIR