MAIN TOPIC SUB-TOPIC SUB-SUB-TOPIC PHARMACOLOGY

ANTEBACTERIAL AGENTS

Pathogen

 An organism that can cause a disease

Human pathogens include

 Viruses  Unicellular organisms

 Bacteria  Multicellular animals
 Fungi

Pathogens may enter through

 Broken skin  Inhalation

 Ingestion  Contact with mucous membrane such as nasal,
urinary or vaginal mucosa

Pathogenicity

Ability of an organism to cause infection

Virulence

Another common word used to describe pathogen

Bacteria

Single celled organisms lacking a true nucleus membrane

Classifying a bacteria

One of the simplest methods of classifying bacteria is to examine them

Microscopically after a crystal violet gram stain is applied

Gram Positive Bacteria

Bacteria contain a thick a thick cell wall and retain a purple color after staining

Example: staphylococci, streptococci, enterococci, clostridium perfingens

Gram Negative Bacteria

Bacteria that have a thinner cell wall will lose the violet stain

Example: bacteroides, Escherichia coli, klebsiella, pseudomonas, salmonella

Second descriptive method is based on cellular shape

Bacteria assumes several basic shapes that can be readily determined microscopically

a) Bacilli – rod shapes

b) Cocci – spherical shapes
c) Spirilla – spiral shape

Staphylococci – cocci that appears in clusters

Streptococci – cocci arranged in chain
Note: Bacteria reproduce by cell division about every 20 minutes

Used to classify bacteria based on their ability to use oxygen

a) Aerobic – thrives in oxygen-rich environment

b) Anaerobic – grow best without oxygen

Antibacterial

 An agent that inhibits bacterial growth or kills bacteria

 Prescribed to combat disease producing microorganism

Note: Antibacterial, antimicrobial, and antibiotic are frequently used interchangeable, there are some subtle differences
in meaning

Antibacterial and Antimicrobials

Are substances that inhibit bacterial growth or kill bacteria and other microorganisms

Antibiotics

Refers to chemical produced by one kind of microorganism that inhibits the microorganism that inhibits the growth of or
kills another

Bacteriostatic

Drugs inhibit the growth of bacteria

Example: tetracycline and sulfonamides have bacteriostatic effect

Bactericidal

Drugs kills bacteria

Example: penicillin and cephalosporins have a bactericidal effect

Mechanism of Antibacterial Action

1. Inhibition of bacterial wall synthesis

2. Alteration of membrane permeability
3. Inhibition of protein synthesis
4. Inhibition of the synthesis of bacterial ribonucleic acid (RNA) and deoxyribonucleic acid (DNA)
5. Interference with metabolism within the cell

ACTION EFFECT DRUGS

Inhibition of cell wall synthesis  Bactericidal effect  Penicillin
 Enzyme breakdown of cell wall  Cephalosporins
 Inhibition of enzymes in synthesis  Bacitracin
of cell wall  Vancomycin
Alteration in membrane  Bacteriostatic or bactericidal  Amphotericin B
permeability effect  Nystatin
 Increase membrane permeability  Polymyxin
 Loss of cellular substances causes  Colistin
lysis of the cell
 ACTION EFFECT DRUGS
Inhibition of protein synthesis  Bacteriostatic or bactericidal  Aminoglycosides
effect  Tetracyclines
 Interferes with protein synthesis  Erythromycin
without affecting the normal cells  Lincomycin
 Inhibit steps of protein synthesis
Inhibition of synthesis of RNA and  Inhibit synthesis of RNA and DNA  Fluoroquinolones
DNA in bacteria
 Binds to nucleic acid and
enzymes needed for nucleic acid
synthesis
Interference with cellular  Bacteriostatic effect  Sulfonamides
metabolism  Interferes with steps of  Trimethoprim
metabolism within the cell  Isoniazid (INH)
 Nalidixic acid
 Rifampin

Pharmacokinetics

 Antibacterial drugs must not only penetrate the bacterial cell wall concentration and have an affinity to the
binding sites on the bacterial cell
 Have a longer haft-life
 Steady state of antibacterial drug occurs after the fourth to fifth half lives
 Eliminated through the urine after the 7 th half life

Pharmacodynamics

 The drug concentration at the site or exposure for the drug plays an important role in bacterial eradication
 Antibacterial drugs are used to achieve a minimum effective concentration (MEC) necessary to halt the growth
of a microorganism

Resistance to antibacterial

 Bacteria maybe sensitive or resistant to certain antibacterial

 When bacteria are sensitive to a drug, the pathogen is inhibited or destroyed
 If the bacteria are resistant to antibacterial, the pathogen continuous to grow, despite the administration of the
antibacterial drug
 Bacterial resistance can be:
 Natural or inherent – resistance occurs without previous exposure to the antibacterial drug
 Acquired resistance – caused by prior to exposure to the antibacterial

Nosocomial infection or Hospital Acquired Infection

 Infection acquired while patients are hospitalized

Methicillin-resistant Staphylococcus aureus (MRSA)

 Highly resistant bacteria

 Resistant not only to methicillin, but to all penicillin and cephalosporins as well
 Vancomycin – treatment of choice for MRSA
General Adverse Reaction to Antibacterial Drugs

 Allergy/hypersensitivity reactions
 Superinfection
 Organ toxicity

Allergy and Hypersensitivity

 Allergic reaction to drugs may be mild to severe

 Sensitivity test must be performed prior to administration of the prescribed dose
 Example of mild reaction
 Rash, Pruritus (severe itching of the skin, a symptoms of a various ailments)
 Hives/urticaria (allergic skin reactions causing localized redness, swelling and itching)
 Example of severe response
 Anaphylaxis – serious allergic response that often involves swelling, hives, lowered blood pressure
x Results in vascular collapse, laryngeal edema
x Bronchospasm and cardiac arrest if not treated immediately can be fatal
x DOB – frequently the first symptoms of anaphylaxis
 Antihistamine – treatment of mild allergic reaction

Superinfection

 Secondary infection that occurs when the normal microbial flora of the body is disturbed during antibiotic
therapy
 Can occur in the mouth, respiratory tract, intestines, GUT and skin
 Rarely develop when the drug is administered for less than 1 week
 Nystatin – used for fungal infection of the mouth

Organ Toxicity

 Liver and kidney are involved in drug metabolism and excretion

 Antibacterial may result in damage to these organs
 Example: aminoglycosides can be nephrotic (as well as ototoxic)

Narrow Spectrum Antibiotics

 Primarily effective against one type of organism

 Example: penicillin and erythromycin are used to treat infection caused by gram positive bacteria

Broad Spectrum Antibiotics

 Effective against gram positive and gram-negative organisms

 Used to treat when the offending microorganism is not identified by C/S test
 Tetracyclines and cephalosporins

Culture Sensitivity Test

Culture

 Test to find germs (bacteria or a fungus) that can cause a disease

Sensitivity Test

 To see what kind of medicine such as antibiotic, will work best to treat the illness or infection
Antibacterial Agents

 Penicillin
 Cephalosporin
 Macrolides
 Tetracycline
 Aminoglycoside
 Fluoroquinolone

Penicillin

 Natural antibacterial agent obtained from the mold genus Penicillium

 Miracle drug
 First mass produced antibiotic
 Pen G was the first to be administered orally and by injection
 Food interferes with absorption

Penicillin V

 Next type of penicillin produced

 Effective against mild to moderate infections, including anthrax as a biologic weapon of bioterrorism

Pharmacotherapy

 Penicillin – kill bacteria by disrupting their cell wall

 Gram positive bacteria – most common affected by penicillin including streptococci and staphylococci
 Indicated for the treatment of pneumonia, meningitis, skin, bone and joint infections
 Mainly referred to as beta lactam antibiotics

Beta Lactam Ring

 Portion of the chemical structure of penicillin that is responsible for its antibacterial activity
 Interferes with bacterial cell wall synthesis by inhibiting the bacterial enzyme that is necessary for cell division
and cellular synthesis

Beta lactamase or Penicillinase

 Bacteria secretes an enzyme

 Bacteria can produce a variety of enzyme that can inactivate penicillin and other beta-lactam antibiotic such as
cephalosporins

Narrow Spectrum/Penicillinase Sensitive

 Penicillin sensitive to cleavage by beta lactamases

 Can act on either gram positive or gram negative but not both
 Penicillin G procaine
 Penicillin G benzathine
 Penicillin G sodium
 Penicillin V potassium
Penicillinase-resistant penicillin (anti-staphylococcal penicillin)

 Effective against penicillinase-producing bacteria

 Used to treat penicillinase producing S aureus
 Example
 Oxacillin (prostaphlin, bactocill)
 Cloxacillin (tegopen, cloxapen)
 Dicloxacillin (dynapen)
 Nafcillin (nafcil, unipen)

Broad Spectrum Penicillin

 Effective against a wide range of microorganism

 Use to treat both gram positive and gram-negative bacteria
 Example
 Ampicillin (polycillin, omnipen)
 Amoxicillin (Amoxil, trimox, himox)
 Amoxicillin – cluvanate (augmentin)
 Bacampicillin (spectrobid)
 Ampicillin – sulbactam (Unasyn)

Extended Spectrum Penicillin (anti-pseudomonal penicillin)

 Effective against even more microbial species including pseudomonas aeruginosa, Enterobacter, Klebsiella and
bacteriodes fragilis
 Example
 Carbenicillin (Geocillin, geopen)
 Piperacillin sodium (pipracil)
 Mezlocillin sodium (Mezlin)
 Piperacillin tazobactam (zosyn)

Beta Lactamase Inhibitors

 Broad spectrum antibiotic (amoxicillin) combined with a beta lactamase (enzyme) inhibitor (clavulanic acid),
resulting antibiotic (amoxicillin-clavulanic acid [Augmentin]) inhibits the bacterial lactamases, making the
antibiotic effective and extending the microbial effect
 Oral use: amoxicillin-clavulanic acid (Augmentin)
 Parenteral use: ampicillin sulbactam (Unasyn), piperacillin-tazobactam (Zosyn) and ticarcillin-clavulanic acid
(Timentin)

General Side Effects and Adverse Reactions

 Hypersensitivity
 Superinfection (occurrence of a secondary infection when the flora of the body is disturbed)
 Nausea
 Vomiting
 Diarrhea
 Rash
 Anaphylactic reaction
 Nursing Interventions

1. Observe for hypersensitivity reaction

2. Carry out C/S test before the start of therapy
3. Check for signs of superinfection like abdominal cramping and diarrhea
4. Examine patient for allergic reaction
5. Check for bleeding with high doses of penicillin
6. Have epinephrine ready for severe allergic reaction
7. Monitor electrolytes and renal function test prior to and during therapy
8. Monitor for hyperkalemia and hyperthermia prior to and during therapy
9. Teach the client to take the medicine completely
10. Administer 1-2 hours before meals or 2 to 3 hours after meals for best absorption
11. Provide small frequent meal, frequent mouth care ice chips or sugarless candy to suck of stomatitis and sore
throat occur
12. Wear a medical alert bracelet if allergic to penicillin
13. Do not give acidic fruit juices because it can inactivate the drugs antibacterial activity
14. Encourage to increase fluid intake
15. Avoid use of penicillin while breast feeding
16. Immediately report rash, severe abdominal or stomach cramps, abdominal tenderness, convulsions, decreased
urine output and severe watery diarrhea or bloody diarrhea
17. Consult with your healthcare provider about taking probiotic supplements or cultured dairy products during
antibiotic therapy

Cephalosporin

 First discovered in seawater-fungus called cephalosporium acremonium

 Are bacteriocidal and act by attaching to penicillin binding proteins to inhibit bacterial cell wall synthesis
 Have a beta lactam ring that is mostly responsible for their antimicrobial activity
 Primary therapeutic use as a class is for gram negative infection and the clients who cant tolerate the less
expensive penicillin
 Effective against gram positive and gram-negative bacteria and resistant to beta lactamase (an enzyme that acts
against the beta lactam structure of penicillin)
 Cause bacteria cell lysis and bacterial cell dies

Four Generations of Cephalosporins

Generation Description Drug Example

First  Most effective against gram positive bacteria (streptococci and  Cephalexin (Keflex)
most staphylococci)  Cefazolin sodium (ancef,
 Effective against most gram negative bacteria (E.coli, species of kefzol)
Klebsiella, Proteus, Salmonella and Shigella)  Cefadroxil (duricef)
 Therapeutic indication:  Cephapirin (cefadyl)
 Respiratory tract (strep pneumonia)
 Otitis media
 Skin infection
Second  More potent, more resistant to beta lactamase, and exhibit a  Cefaclor (ceclor)
broader spectrum against gram negative organisms (Haemophilus  Cefuroxime (ceftin,
influenzae, Neisseria gonorrhea, Neisseria meningitidis and several kefurox, zinacef)
anaerobic organisms) than the first-generation drugs  Cefmetazole (zefazone)
 Less effective against gram positive bacteria
 Generation Description Drug Example
Third  Have a longer duration of action than 2 nd generation agents  Cefixime (suprax)
 Broader spectrum against gram negative organisms, and are  Cefdinir (Omnicef)
resistant to beta lactamase  Ceftriaxone (rocephine)
 Sometimes the drug of choice against infection by pseudomonas,  Cefotaxime (claforan)
klebsiella, Neisseria, proteus, and haemophilus influenza
 Less effective against gram positive bacteria
Fourth  Effective against organisms that have developed resistance to  Cefepime (Maxipime)
earlier cephalosporins
 3rd and 4th generation agents are capable of entering the NOTE: monitor I/O, blood
cerebrospinal fluid (CSF) to treat CNS infections uera nitrogen (BUN), serum
 Effective against E. coli, klebsiella, proteus, streptococci, certain creatinine
staphylococci, Pseudomonas aeruginosa

Side Effects and Adverse Reactions

GI System (common)

 Nausea  Anorexia
 Vomiting  Abdominal pain
 Diarrhea  Flatulence

CNS

 headache  lethargy
 dizziness  paresthesia

Renal System – nephrotoxicity in individuals with existing renal disease

 fatigue, pruritus, pain on the injection site

 pseudomembranous colitis, nephrotoxicity, and anaphylaxis – serious adverse reaction

DRUG-to-DRUG Interactions

 If taken with alcohol

 May result to disulfiram (Antabuse)
 Symptoms of this reaction include:

x Severe vomiting x Nausea

x Weakness x Flushing
x Blurred vision x Dizziness
x Profound hypotension x Headache

 Disulfiram like drug – a drug that causes an adverse reaction to alcohol

Nursing Interventions

1. C/S should be done before the therapy

2. Assess for the presence or history of bleeding disorders because cephalosporins may reduce prothrombin levels
through interference with vitamin K metabolism
3. Assess the renal and hepatic function, because most cephalosporins are eliminated by the kidney, and liver
function is important in vitamin K production
4. Use with caution on clients with penicillin allergy
 5. Use with caution in pregnant or lactating because the drug can be transferred to the fetus

Client Teachings

 Avoid alcohol use

 Eat cultured dairy products to help discourage superinfection like yogurt, kefir
 May cause false positive urine glucose test
 Keep drugs out of reach of small children
 Use childproof containers
 Report signs of superinfection – mouth ulcers, discharge from genital or anal area
 Ingest buttermilk or yoghurt to prevent superinfection of intestinal flora
 Take complete course of medication even if infection have ceased
 Observe for hypersensitivity reaction

Tetracyclines

 Acts by inhibiting bacterial protein synthesis, by binding to the bacterial ribosome and have a bacteriostatic
effect
 Isolated from streptomyces aureofaciens in 1948
 The first broad spectrum antibiotics effective against gram-positive and gram-negative bacteria and many other
organisms – mycobacteria, rickettsiae, spirochetes and clamydiae
 Example of tetracycline drugs
 Demeclocycline (Dectomycin)
 Doxycycline (Vibramycin, others)
 Minocycline (Minocin)
 Methacycline (Rondomycin)
 Tetracycline (Achromycin, others)
 Tigecycline (Tygacil)

Therapeutic Effects Adverse Effects

 Rocky mountain spotted fever GI System
 Typhus  Nausea and vomiting
 Cholera  Diarrhea
 Lyme disease Musculoskeletal
 Peptic ulcers caused by helicobacter pylori  Tetracycline accumulates on teeth and bones
 Chlamydial infections leading to weakening of the bones/teeth
 Permanent staining
 Discoloration
Skin
 Rashes
 Photosensitivity – an extreme sensitivity to
ultraviolet rays from the sun and other light
sources

DRUG-to-DRUG Interactions

 Penicillin – decrease effectiveness

 Oral contraceptives – decrease effectiveness – advice alternative methods of contraception
 Digoxin – toxicity rises
 DRUG-FOOD Interaction

 Dairy products – render unabsorbable

 Give on an empty stomach
 Ca and Fe bind – decrease drug absorption

Nursing Considerations

1. Assess for a history of hypersensitivity to tetracyclines

2. Obtain C/S results before therapy is initiated
3. Assess for the presence of history of acne vulgaris, actinomycosis, anthrax, malaria, syphilis, UTI, rickettsia
infection, and Lyme disease (Tetracycline can treat all this disease)
4. Perform CBC and kidney and liver functions studies
5. Monitor the clients body temperature and WBC and C/S results to determine the effectiveness of the treatment
and observe for superinfections
6. Protect the patient from exposure to the sun with adequate clothing and sunscreen
7. Instruct the patient to take the meds without food and with full glass of water
8. Provide alternative contraceptives methods during the course of therapy
9. Use with caution in clients with impaired kidney or liver function
 Contraindicated to pregnancy or lactation and children below 8 years old

Client Teachings

 Do not save medication – toxic effects may occur if it is taken past the expiration date
 Do not take these medications with milk products, iron supplements, magnesium-containing laxatives or
antacids
 Wait 1 to 3 hours after taking tetracyclines before taking antacids
 Wait at least 2 hours before or after taking tetracyclines before taking lipid-profile drugs such as colespitol
(Colesid) and cholestyramine (Questran)
 Complete the full course of treatment
 Immediately report abdominal pain, loss of appetite, nausea and vomiting, visual changes and yellowing of the
skin
 Avoid exposure to direct sunlight: use sunscreen and protective clothing to decrease the effects of
photosensitivity

Macrolides

 Inhibit protein synthesis by binding to the bacterial ribosome

 Bind to the bacterial cell ribosomes and change or alter protein production/function leading to impaired cell
metabolism and division
 Effective against most gram positive and many gram-negative species
 Indicated for the pharmacological treatment of respiratory disorders
 Safe alternative to penicillin
 Example of Macrolides drugs
 Axithromycin (Zithromax)
x Has extended haft life that is administered only for 3 to 4 days
 Clarithromycin (Biaxin)
 Dirithromycin (Dynabac)
 Erythromycin (E-mycin, Eryhtromycin)
x First macrolides, was derived from the fungus-like bacteria Streptomyces erythreus in 1950
 Indications

 For treatment of Whooping cough, legionnaires disease and infection by streptococcus, H. influenza, and
Mycoplasma pneumoniae
 Used against bacteria inside host cells such as listeria, chlamydia, dyptheria, pertussis and gonorrhea

Adverse Effects

 GI system

 Diarrhea  Vomiting
 Abdominal cramps  Pseudomembranous colitis
 Anorexia

 CNS
 Reversible hearing loss
 Tinnitus
 Vertigo
 Skin
 Rashes
 urticaria
 Hepatoxicity - if taken in large dose with other hepatoxic drugs
 Anaphylaxis
 Ototoxicity

Drug Interactions

 Macrolides can increase serum level of theophylline (bronchodilator), carbamazepine (Anticonvulsant), and
warfarin (anticoagulant) – closely monitor the drug serum level
 Erythromycin – should not be used with other macrolides to avoid severe toxic effect
 Antacids – may reduce zithromycin peak levels when taken at the same time

Nursing Considerations

1. Assess for the presence of respiratory infections

2. Assess for GI tract infections, skin and soft-tissue infections, otitis media, gonorrhea
3. Examine the patient for a history of cardiac disorders, because macrolides may exacerbate existing heart disease
4. Assess for history of hypersensitivity
5. Obtain C/S testing before initiating macrolide therapy
6. Do not administer macrolides to client with serious hepatic impairment
7. Used cautiously in pregnant or breastfeeding woman to avoid harm to the fetus or newborn
8. Macrolides should be used cautiously in clients receiving Cyclosporine (Sandimmune) and drug level must be
monitored because of high risk of Nephrotoxicity
9. Perform coagulation laboratory studies such as international normalized ratio (INR)
 Closely monitor client receiving warfarin (Coumadin) because macrolides may decrease warfarin metabolism
and excretion

Client Teaching

 Complete the full course of treatment

 Do not take macrolides with fruit juices
  Do not take other prescription drugs or OTC medications, herbal medicines, vitamins and minerals without
informing health care provider
 Immediately report severe skin rashes, itching or hives, DOB, jaundice, dark urine or pale stools

Aminoglycosides

 Bacteriocidal and act by inhibiting bacterial protein synthesis and causing synthesis or abnormal proteins
 Streptomycin – first aminoglycosides and was name after Streptomyces griseus, the soil organism from it was
isolated in 1942
 Used to treat tuberculosis
 Drug of choice to treat tularemia and bubonic pneumonic forms of plaque

Therapeutic use

 Reserved for serious systemic infections caused by aerobic gram-negative organisms including those caused by
E. coli, Serratia, proteus, klebsiella and pseudomonas
 Sometimes administered concurrently with penicillin, cephalosporins, or vancomycin for treatment of
enterococci infections
 When used for systemic bacterial infection, aminoglycosides are given parenterally (IM, IV) because they cannot
be absorbed from GI tract and cannot cross into the placenta
 Neomycin – frequently used as preoperative bowel antiseptic
 Paromomycin – useful in treating intestinal amoebiasis and tapeworm manifestation given orally
 Example of Aminoglycosides drugs
 Amikacin (Amikin)
 Gentamicin (Garamycin, others)
 Kanamycin (Kantrex)
 Neomycin (Mycifradin)
 Netilmicin (Netromycin)
 Paromomycin (Humantin)
 Streptomycin
 Tobramycin (Nebcin)

Adverse Reactions Serious Adverse Reaction

 Pain on the injection sites  Nephrotoxicity
 Rash  Abnormal urine function test
 Fever  Elevated serum creatinine or BUN
 Nausea  Ototoxicity
 Diarrhea  Hearing impairment
 Dizziness  Dizziness
 Tinnitus  Loss of balance
 Persistent headache
 Ringing in the ear (tinnitus)
 Anaphylaxis

Nursing Considerations

 Assess the client for a history of previous allergic reaction to aminoglycosides

 Monitor for nephrotoxicity and ototoxicity during the course of therapy
 Assess baseline auditory and vestibular functions prior administration and through out the therapy
 Assess baseline renal function and obtain results of urinalysis
 Used with caution in neonates, infants and elderly clients
 Client Teaching

 Increase fluid intake

 Complete the full course of treatment
 Immediately report tinnitus, high frequency hearing loss, persistent headache, nausea or vertigo
 Monitor clients for diarrhea, stomatitis, glossitis and vaginal discharge

Fluoroquinolones

 Bacteriocidal and affect DNA synthesis by inhibiting two bacterial enzymes: DNA gyrase and topoisomerase
 To interfere with the enzyme DNA gyrase, which is needed to synthesize bacterial deoxyribonucleic acid (DNA)
 Once reserved only for UTI’s because of their toxicity

Therapeutic Use

 Effective against some gram-positive organisms, such as Streptococcus pneumoniae and against Haemophilus
influenzae, P. aeruginosa, Salmonella and Shigella
 Useful in the treatment of UTI, bone and joint infection, bronchitis, pneumonia, gastroenteritis, gonorrhea,
typhoid
 Ciprofloxacin (Cipro) – an agent of choice for postexposure prophylaxis of bacillus anthracis
 Moxifloxacin (Avelox) and Trovafloxacin (Trovan) – highly effective against anaerobes
 Levofloxacin (Levaquin) – to treat respiratory problems such as CAP, chronic bronchitis, acute sinusitis, and UTI

Fluoroquinolones Drugs

Generation Drugs
First  Nalidixic acid (neogram) – first drug in this class, approved in 1962
 Had a narrow spectrum of activity and was restricted use to UTI
Second  Ciprofloxacin (Cipro)
 Norfloxacin (Noroxin)
 Ofloxacin (Floxin)
 Lomefloxacin (Maxaquin)
Third  Gatifloxacin (tequin)
 Levofloxacin (Levaquin)
Fourth  Gemifloxacin (Factive)
 Moxifloxacin (Avelox)
 Trovafloxacin mesylate (Trovan)

Adverse Effects

 GI system – most common side effects

 Nausea  Vomiting  Diarrhea

 Dry mouth, rash, restlessness, pain and inflammation at the insertion site, local burning, stinging and corneal
irritation (ophthalmic)
 CNS

 Dizziness  Headache
 Insomnia  Depression
 Hema
 Bone marrow depression
 Photosensitivity
 Dysrhythmias (Gatifloxacin and Moxifloxacin) and liver failure (Trovafloxacin) – most serious adverse effects

Contraindications and Precaution of Fluoroquinolones

 Found to cause significant damage to the cartilages that they are given cautiously to growing children and
adolescents less than 18 years old example – Ciprofloxacin (Cipro)
 Pregnancy and lactation
 Caution to client with epilepsy, cerebral atherosclerosis

Nursing Considerations

1. Assess for allergic reaction to fluoroquinolones

2. Monitor WBC count – agent may decrease leukocytes
3. Obtain culture and sensitivity test
4. Monitor clients with liver and renal dysfunction – drug is metabolized in the liver and excreted in kidney
5. Antacids and ferrous sulfate may decrease the absorption of fluoroquinolones – reducing antibiotic effectiveness
6. Give enoxacin (Penetrex) and Norfloxacin (Noroxin) on an empty stomach
7. Administer fluoroquinolones at least 2 hours before these drugs
8. Frequently monitor coagulation studies if these antibiotics are administered concurrently with Warfarin
(Coumadin) – because of interactions that may lead to increase anticoagulation effects
9. Monitor urine output and report quantities of less than 1000 mL in 24 hours
 Inform clients receiving Norfloxacin (Noroxin) that photophobia is possible

Client Teaching

 Wear sunglasses, avoid exposure to bright lights and direct sunlight when taking Norfloxacin (Noroxin)
 Complete the full course of treatment
 Immediately report signs of tendon pain or inflammation
 Immediately report dizziness, restlessness, stomach distress, diarrhea, psychosis, confusion or irregular or fast
heart rate
 ANTI INFECTIVE AGENTS

Anti-Infective

 A general term for any medication that is effective against pathogens

 Although antibiotic is more frequently used, there term refers only to natural substances produced by
microorganism that can kill another microorganism

Bacteriocidal/Bactericidal

 Medications that accomplish this goal by killing the bacteria ‘

Bacteriostatic

 This drug will not kill the bacteria but instead slow their growth, depending on the body’s natural defense to
dispose microorganism
 Growth slowing drugs

Mutation or Errors in Genetic Code

 Microorganism have the ability to replicate extremely rapidly

 Occur spontaneously and randomly throughout the bacterial chromosomes

Acquired Resistance

 Clients develops an infection that is resistant to conventional drug therapy

Broad Spectrum Antibiotic

 Effective against many different species of pathogens

Narrow Spectrum Antibiotic

 Effective against only one or a restricted group of microorganisms

Culture and Sensitivity Test

 Process of growing the pathogen and identifying the most effective antibiotic

Superinfection

 Appearance of secondary infection

 Occur when microorganisms normally present in the body are destroyed

Host Flora

 Normal microorganism, inhabit the skin, upper respiratory, genitourinary and intestinal tract

Note: The primary goal of antibiotic therapy is to kill enough bacteria, or to slow the growth of the infection, so that
natural body defenses can overcome the invading agent

Anti-infective Agents

 Antituberculars
 Antifungals
 Antivirals
  Antiprotozoan
 Antihelminthics

Antitubercular Drugs

Tuberculosis

 Caused by the acid-fast bacillus Mycobacterium tuberculosis or tubercle bacillus

 One of the worlds major health problems, killing one person than any other infectious disease, including
acquired immunodeficiency syndrome (AIDS) – immune disorder characterized by opportunistic diseases
 Tubercles – slow growing mycobacterium usually become dormant, existing inside cavities

Antitubercular drugs

 Agents that treat tuberculosis

Streptomycin o The first drug used to treat TB, and is given parenteral antibiotic
Isoniazid (INH) o The first oral drug preparation effective against the tubercle bacillus and was discovered
in 1952
o A bacterial drug that inhibits tubercle cell wall synthesis and blocks pyridoxine (Vitamin
B6), which is used for intracellular enzyme production

Note: Drug therapy of TB differs from that of most other infections. Mycobacteria have a cell wall that is resistant to
penetration by antibiotic

Months Description
6 to 12 months Medications to reach the isolated microorganism in the tubercles
24 months Needed when the clients develop multidrug resistant
6 to 24 months Different combinations of drugs may be used; at least 2 and sometimes 4 or more antibiotics
is administered concurrently

2 Broad Categories of Antitubercular Drugs

First Line Drugs

 Safer and generally the most effective

 Ethambutol (Myanbutol)
 Isoniazid (INH)
 Pyrazinamide (PZA)
 Ryfampin (Rifanid, Rimactane)
 Rifapentine (Priftine)
 Rifater (combination of PZA with INH and rifampin)
 Streptomycin

Second Line Drugs

 More toxic and less effective than the first line drugs
 Used when resistance develops
 Amikacin (Amikin)
 Capreomycin (Capastat sulfate)
 Ciprofloxacin (Cipro)
 Cycloserine (Seromycin)
 Ethionamide (Trecator-SC)
  Kanamycin (Kantrex)
 Ofloxacin (Floxin)

Combination of INH and PZA

 Approved for tuberculosis prophylaxis in HIV positive patients for a short-term therapy of 2 months

Rifampin and PZA

 Recommended to HIV positive patient with positive TB skin test as prophylactic for 2 months

Isoniazid

 Primary antitubercular drug used and may cause isoniazid-induced liver damage
 Must be taken with Pyridoxine (Vitamin B6) to avoid deficiency and peripheral neuropathy

2 Types of Mycobacteria Infects Humans

Mycobacterium leprae

 Responsible for leprosy

 Treated with multiple drugs, usually beginning with Rifampin

Mycobacterium avium complex (MAC)

 Causes infection of the lungs, most commonly observed in AIDS

 Macrolides Azithromycin (Ztihromax) and Clarithromycin (Biaxin) – Effective drugs against MAC

Multidrug Therapy

 Isoniazid and Rifampin

 Isoniazid, Rifampin and Ethambutol
 Isoniazid, Rifampin and Pyrazinamide

Pharmacokinetics

 INH – well absorbed in the GI tract

 Administered IM
has low protein binding rate (10%
 Half-life: 1 – 4 hours
 Isoniazid is metabolized in the liver and 75% of the drug excreted in the urine

Pharmacodynamics

 Inhibits cell wall synthesis of the tubercle bacillus

 Peripheral neuropathy is an adverse reaction to isoniazid, so pyridoxine (Vitamin B6) is usually taken to decrease
probability of neuropathy
 Should not be taken with alcohol will increase the incidence of peripheral neuropathy
 Antacids decreases isoniazid absorption
 If phenytoin is taken with isoniazid, the effect of phenytoin will decrease

Side Effects and Adverse Effects

Isoniazid Peripheral neuropathy

INH, Rifampin, Streptomycin Hepatotoxicity, patient may develop headache, blood dyscrasias, paresthesia’s, GI
distress and ocular toxicity
Rifampin Turns body fluids orange
 Ethambutol May develop dizziness, confusion, hallucination and joint pains
Streptomycin Ototoxicity, optic nerve toxicity, encephalopathy, angioedema, CNS and respiratory
depression nephrotoxicity and ototoxicity
Nursing Considerations

1. Assess for the presence of or history of a positive tuberculin skin test, positive sputum culture, or a close contact
to a person recently infected with TB
2. Assess the patient for a history of alcohol abuse, AIDS< liver disease, or kidney disease because many
antituberculosis drugs are contraindicated in those conditions
3. Assess for concomitant use of immunosuppressant drugs
4. Use caution in clients with renal dysfunction, pregnancy and lactation
5. Use caution to a client with history of convulsive disorder
6. Used caution with in clients having chronic liver disease or alcoholism because of the risk of hepatic injury due to
the production of toxic levels of drug metabolites
7. Ethambutol (Myambutol) is contraindicated in clients with optic neuritis
8. Antituberculosis drugs interact with oral contraceptives and decrease their effectiveness, female clients with
childbearing potential should use an alternative form of birth control

Client Teachings

 Immediately report yellow eyes and skin, loss of appetite, dark urine or unusual tiredness
 Take supplemental vitamin B6 as ordered to reduce risk of adverse effects
 If taking isoniazid, avoid foods containing tyramine, such as age cheese, smoked and pickled fish, beer, and red
wine, bananas and chocolate
 Wash hands frequently and cover the mouth when coughing, or sneezing; properly dispose of soiled tissues
 If taking oral contraceptives, use an alternative form of birth control during antitubercular drug therapy
 Complete the full course of treatment

Anti-Fungal Drugs

Fungi

 Single-celled or multicellular organisms whose primary role on the planet is to serve as decomposers of dead
plants and animals, returning their elements to the soil for recycling
 Includes mushroom, yeast and molds
 Also known as dermatophytes
 Cause superficial fungal infections involving the integumentary system, including the mucous membranes, hair,
nails and moist skin areas and respiratory tract

Lungs

 Serves as a route for invasive fungi to enter the body and infect internal organ

Classification of Fungal Infection

Opportunistic Infection

 Usually occur in the immunocompromised of debilitated population (patient who have cancer or AIDS) or those
taking antibiotic, corticosteroid, chemotherapy, or other immunosuppressives
 Candida – part of the normal flora of the mouth, skin, intestines and vagina
 Examples of opportunistic infection are:
 Aspergillosis
 Cryptococcosis
 Mucormycosis
Non-opportunistic Infection

 Such as the following which can occur in any individual

 Sporotrichosis
 Blastomycosis
 Histoplasmosis
 Coccidioidomycosis

Classification of Mycoses – fungal diseases

Superficial mycoses

 Affect the scalp, skin, nails and mucous membranes such as the oral cavity and vagina
 Mycoses in this type are often treated with topical drugs because the incidence of side effects is much lower
using this route of administration
 Super fungal infections – sometimes called Dermatophytic

Systemic Mycoses

 Affecting internal organs, typically the lungs, brain and digestive organs
 Affects multiple body system and are sometimes fatal to client with suppressed immune system
 Systemic mycoses require aggressive oral or parenteral medications that produce more adverse effects than the
topical agents

Antifungal drugs/antimycotic drugs

 Used to treat fungal infections

 They are fungistatic or fungicidal depending upon the susceptibility of the fungus and the dosage

Antifungal Drugs example

 Antimycotic drugs
 Polyenes (amphotericin B and nystatin)
 Azoles (ketoconazole)
 Antimetabolites (flucytosine)
 Echinocandins (caspofungin)
 Antiprotozoals (atovaquone)

Drugs for Systemic Antifungal infections

 Amphotericin B (Fungizone, Abelcet, amphotec)

 Fungizone – drug of choice for systemic fungal infections and currently with close supervision because it
can cause number of serious side effects
 Amphotericin B is effective against numerous fungal diseases, including histoplasmosis, Cryptococcis,
Aspergillosis, blastomycosis, and candidiasis (systemic infection)

Pharmacokinetics Pharmacodynamics Side Effects and Adverse Reaction

o Highly protein bound and has a
long haft life
o 5% of the drug is excreted in the
urine
o Amphotericin B is not absorbed o Flush
from the GT tract o Fever
o Administered IV in low doses in o Chills
treating systemic fungal infection o Nausea
o Peak effect occurs 1 to 2 hours o Hypotension, paresthesia’s,
after IV infusion and the duration thrombophlebitis
 is 20 hours o Nephrotoxicity and electrolyte
imbalance especially
hypokalemia and
hypomagnesemia (low potassium
and magnesium level)

 Anidulafugin (Eraxis)
 Caspufungin acetate (Cancidas)
 Flucytosine (5-fluorocytosine, ancobon)
 Ancobon – sometimes combined with Amph. B in the pharmacotherapy of severe candidiasis
 Can cause immunosuppression and liver toxicity and resistance has become a major problem
 Micafungin (Mycamine)
 Intraconazole
 Drug of choice for the treatment of less severe systemic infections

Nursing Considerations: Systemic Antifungal Therapy

1. Careful monitoring of client’s condition and providing education as it relates to the prescribed drug treatment
2. Contraindicated with clients with known hypersensitivity to antifungal drugs
3. Used cautiously in those with renal impairment or severe bone marrow suppression and in pregnancy
4. Obtain baseline C/S prior to beginning therapy
5. Obtain baseline and periodic lab test including blood urea nitrogen (BUN), creatinine, CBC, electrolytes and liver
function test
6. Obtain V/S especially pulse and blood pressure, for baseline data because clients with heart disease may
develop fluid overload
7. Closely monitor intake and output as well as weight
8. Immediately report oliguria, changes intake and output ratios, hematuria or abnormal renal function tests
9. Can cause ototoxicity, assess for hearing loss, vertigo, unsteady gait or tinnitus

Client Teaching

 Complete the full course

 Keep all scheduled appointments and laboratory visits for testing
 Avoid alcohol use
 Report changes in appetite, weight loss, or jaundice
 Practice reliable contraception and notify your healthcare provider if pregnancy is planned or suspected
 Monitor urine output and drink plenty of fluids
 Report any change in urine output

Azole

 Azole groups is effective against candidiasis (superficial and systemic)

 It consists of two different chemical classes, the imidazole and the triazoles

Azole Antifungal Drugs

 Interfere with the biosynthesis of ergosterol, which is essential for fungal cell membranes

Azole class

 Largest and most versatile group of antifungals

 Drugs in this class have broad spectrum and maybe used to treat any fungal infection
 Azole Drug Description
Ketoconazole First effective antifungal drug that was orally absorbed

Fluconazole (Diflucan) Used for both systemic and topical infections

Intraconazole
(Sporanox)
Ketokonazole (Nizoral),
Voriconazole (Vfend)

Clotrimazole (Mycelex) Drug of choice for superficial fungal infections of the skin, vagina and mouth

Most Common Adverse Effect of Systemic Azole are

 Nausea and vomiting severe nausea may require dose reduction or concurrent administration of antiemetic
 Anaphylaxis and rash
 Menstrual irregularities
 Gynecomastia in men and decline in testosterone level
 Decreased libido and temporary sterility in men

Nursing Considerations: Azole Antifungals

1. Contraindicated to client with hypersensitivity to azole antifungals

2. Used with caution in clients with renal impairments
3. Obtain BUN, creatine and liver function test before therapy begins and throughout the course of treatment
4. Do not give ketoconazole (Nizoral) to clients with chronic alcoholism, because additive hepatoxicity may occur
5. Assess for GI side effects like nausea, vomiting, abdominal pain, or diarrhea
6. Monitor for signs of hepatoxicity like pruritus, jaundice, dark urine and skin rash

Client Teachings: Azole Drugs

 Complete the full course of treatment

 Report the use of any other prescription or OTC medications, herbal remedies, or dietary supplements
 Avoid alcohol use
 Monitor urine output and drink plenty of water
 Practice reliable contraception and notify your health care provider if pregnancy is planned or suspected
 Immediately report increased GI distress, anorexia, weight loss, jaundice, yellow sclera or dark urine
 If diabetic, increase the frequency of blood glucose monitoring and report hypoglycemia

Drugs for Superficial Fungal Infections

Superficial mycoses

 Generally, not severe

 Agents used to treat superficial mycoses are
 Nystatin (Mycostatin, nilstat, nystex)
 Terbinafine (Lamisil)
 Tolnaflate (Aftate, Tinactin)
Superficial antifungal drugs

 Much safer than their systemic counterparts

Drugs
Nystatin (Mycostatin)
Griseofulvin (Fulvicin)
Itraconazole (Sporanox)
and Tebinafine (Lamisil)
Miconazole and
Clotrimazole
Tolnaflate and
Undecyclenic acid
Description
o Administered orally or topically to treat candida infections
o Available in suspension, cream, ointment, and vaginal tablet
o Poorly absorbed via GI Tract however the oral tablet form is to treat intestinal
candidiasis
o More common used is in oral suspension for candida infections in the mouth
o An expensive, older agent given the oral route that is indicated for mycoses of the
skin, hair and nails that have not responded to conventional topical preparations
o Oral preparations that have the advantage of accumulating in nail beds, allowing
them to remain active many months after therapy is discontinued
o Over the counter drugs (OTC) drugs of choice for vulvovaginal candida infections
o Frequently used to treat athletes’ foot and jock itch

Nursing Considerations

1. Assess for signs of contact dermatitis, if this present withhold the drug and notify the primary health care
provider
2. Do not use superficial antifungals, such as nystatin (mycostatin), intravaginally during pregnancy to treat
infection caused by Gardnerella vaginalis or trichomonas species
3. Use cautiously in clients who are lactating
4. The medications maybe “swished and swallowed” when used to treat oral candidiasis. Monitor for side effects
such as nausea, vomiting and diarrhea when the client is taking high doses
5. Monitor for signs of improvement in the mouth and tongue to evaluate the effectiveness of the medication

Client Teaching: Superficial Antifungal Therapy

 Complete the full course of treatment: some infections require pharmacotherapy for several months
 If self-treating with OTC preparations, follow the direction carefully and notify the health care provider if
symptoms do not resolve in 7 to 10 days
 Abstain from sexual intercourse until treatment for vaginal infection has been completed
 Perform oral hygiene before using oral lozenges or swish- and swallow formulations

Anti-Protozoal Drugs

Protozoa

 Single celled animals

 These parasites often thrive in condition where sanitation and personal hygiene are poor and population density
is high
 Protozoal infection often occurs in clients who are immunocompromised

Antiprotozoal agents

 Used in treatment of protozoan infections

Antiprotozoal drugs
  Medicine or drugs used to treat infections or disease caused by protozoa
 These drugs destroy protozoa or prevent their growth and ability to produce
 Available in liquid, tablet and infectable forms

Common diseases caused by protozoa are

 Malaria, Amoebiasis, sleeping sickness

 Toxoplasmosis, trichomoniasis
 Pneumocystis Carinii Pneumonia (PCP)

Prototype Mechanism of Action Nursing Consideration Client Teaching

Antimalarial Drugs
-Atovaquone and proguanil Alters protozoal DNA, 1. Antimalarial drugs are  Complete the full
(malarone) depleting folates and contraindicated in course of treatment
-Chloroquine hydrochloride reducing nucleic acid clients with  Take the drugs with
(aralen) production hematological food to decrease GI
-Hydrochloroquinesulfate disorders or severe skin upset
(Plaquenil) disorders such as  Change position slowly
-Mefloquine (Lariam) psoriasis or during to avoid dizziness
-Primaquine Phosphate pregnancy  Practice reliable
-Pyrimethamine (Daraprim) 2. Used cautiously in contraception and
-Quinine (Quinam) clients with pre- notify your health care
existing cardiovascular provider if pregnancy is
disease and those who planned or suspected
are lactating  Avoid alcohol use
3. Initial lab words  Use caution while
include a CBC, liver and performing hazardous
renal function test and activities
a test for G6PD  Immediately report
deficiency; Chloroquine flushing, rashes,
(Aralen) may edema, itching,
precipitate anemia in tinnitus, blurred vision
clients with G6PD or seizures
deficiency and may
cause bone marrow
depression
4. Obtain a baseline ECg
because of potential
cardiac complications
associated with
antimalarial drugs
5. Obtain baseline V/S
especially BT, BP and
hearing and vision
testing
6. Monitor for GI side
effects such as
vomiting, diarrhea and
abdominal pain; oral
antimalarials can be
given with food to
reduce GI upset
7. Assess for signs of

-Metronidazole (Flagyl)
-Furozolidone (Furoxone)
-Iodoquinol
allergic reactions such
as flushing, rashes,
edema and pruritus
8. Monitor for signs of
toxicity, which includes
tinnitus with quinine,
and severe cardiac
complications and CNS
complications such as
seizures and blurred
vision with chloroquine
Antiamebiasis
Block protein synthesis

Pharmacotherapy of nonmalarial protozoal infections

Plasmodium

 Most significant protozoal disease worldwide, infections caused by other protozoans affect significant numbers
of people in endemic areas
 This includes:
 Amoebiasis, toxoplasmosis, giardiasis
 Cryptosporidiosis, trichomoniasis
 Trypanosomiasis, leishmaniasis

Amoebiasis

 Severe form of diarrhea, the primary symptoms is amebic dysentery

Metronidazole (Flagyl) Traditional drug of choice for non-malarial protozoal infections like amoebiasis
Tinidazole (Tindamax) o Approved by FDA for the treatment of trichomoniasis, giardiasis and amoebiasis
o This is similar to metronidazole but has a longer duration of action that allows for less
frequent dosing

Nursing Considerations: Nonmalarial drugs

1. Antiprotozoal therapy is contraindicated in clients with blood dyscrasias or active organic disease of the CNS and
during the 1st month of pregnancy
2. Contraindicated in alcoholics; the medication is not administered until more than 24 hours after the clients last
drink of alcohol
3. Used cautiously in clients with peripheral neuropathy or pre-existing liver disease and if there is a history of
bone marrow depression, because the drug may cause leukopenia
4. Safety and efficacy have not been established to children
5. Obtain initial lab test including a CBC and thyroid and liver function studies
6. Obtain a baseline V/S and evaluate other drugs taken by the client for compatibility with antiprotozoal drugs
7. Closely monitor V/S and thyroid function during therapy because serum iodine may increase and cause thyroid
enlargement with Iodoquinol (Yodoxin)
8. Monitor for GI distress: oral medications can be given with food to decrease the incidence of nausea and
vomiting
9. Clients taking metronidazole (Flagyl) may complain of a dry mouth and metallic taste
 10. Monitor for CNS toxicity such as seizures, paresthesia, and for allergic reaction such as urticaria and pruritus

Client Teaching: Nonmalarial drugs

 Complete the full course of treatment

 Take the drug with foods to decrease GI upset
 Practice reliable contraception and notify the health care provider if pregnancy is planned or suspected
 Avoid using hepatotoxic drugs including alcohol to avoid a possible disulfiram-like reaction (flushing, tachycardia,
severe headache, palpitations, hypotension, dyspnea)
 Recognize the urine may turn reddish brown as an effect of the medication
 Have any sexual partners treated concurrently to prevent reinfection
 Immediately report seizures, numbness in limbs, nausea, vomiting, hives or itching

Antiviral Drugs

Viruses

 Non living agents that infect bacteria, plants, and animals

 Contain none of the cellular organelles necessary for self-survival that are present in living organisms
 More difficult to eradicate than most type of bacteria
 Viruses enter healthy cells and use their DNA and RNA to generate more viruses

Antiviral drugs

 Class of medication used specifically for treating viral infections rather than bacterial ones
 Most antivirals are used for specific viral infections
 Antiviral drugs do not destroy their target pathogen; instead, they inhibit their development

Broad Spectrum antiviral

 Effective against a wide range of viruses

Therapeutic Use Mechanism of Action Adverse Effects

-Designed to help deal with HIV, Inhibit virus specific enzymes involve o Granulocytopenia,
herpes viruses, hepatitis B and C in DNA synthesis. They control the thrombocytopenia
viruses, and influenza A and B growth of virus but does not cure o Nausea, nervousness, headache
 Acyclovir (Zovirax), o Nephrotoxicity
Ganciclovir (Cytovene)
 Vidarabine (Vira-A),
Amantidine (Symmetrel)
 Ribavarin (Virazole),
Zidovidine (Retrovir)

Drugs Description
Acyclovir o Introduced as an antineoplastic drug and then later was found to be effective against
herpes virus especially to herpes zoster (Shingles)
o Interferes with the viral synthesis of DNA, thereby short-circuiting its replication

Oseltamivir o Treat acute uncomplicated influenza

phosphate (Tamiflu)
Penciclovir o Treatment for herpes labialis
Nursing Considerations

1. Pregnant and breastfeeding precautions

2. Administer IV antivirals to avoid crystallization in renal tubules
3. Give Ribavirin only with aerosol generator
4. Monitor CBC and creatinine level
5. Refer for signs of bleeding
6. Take amantadine after meals

Antiviral HIV Drugs

 Reverse transcriptase inhibitor

 Didanosine (Videx)
 Zalcitabine (Hivid)
 Zidovudine (Retrovir)
 Protease inhibitors
 Indinavir (Crixivan)
 Ritonavir (Norvir)

Anti-helminthic drugs

Helminths

 Consist of various species of parasitic worms which have more complex anatomy, physiology and life cycles than
the protozoans
 Most common site for helminthiasis (worm infestation) is in the intestines
 Other sites for parasitic infestation are the lymphatic system, blood vessels, and livers

Group of helminths include

1. Cestodes (tapeworms)
2. Trematodes (flukes)
3. Intestinal nematodes (round worms)
4. Tissue invading nematodes (tissue round worms and filariae)

Anti-helminthic drugs

 Medicines that rid the body of parasitic worms

 Available with physicians’ prescription

Prototype Mechanism of Action Adverse Effects

 Mebendezole (vermox),
thiabendazole
 Niclosamide (Niclocide)
 Piperazine (Antepar)
 Praziquantel (Biltricide)
Paralyze larva and adult helminths by
acting on parasite microtubules
o GI distress
 Anorexia, vomiting, nausea,
and occasionally diarrhea and
stomach cramps, urinary
odor (thiabendazole)
o Neurologic problems
 Dizziness, weakness,
headache and drowsiness,
fatigue
Health Teachings

1. Treat all the family members for nematodes infection to prevent recurrence
2. Praziquantel must be swallowed rapidly because of its bitter taste to avoid gagging
3. Other antihelmintic drugs should be chewed
4. Complete the full course of treatment
5. Have close personal contacts treated concurrently to prevent reinfestation
6. Report itching and hives, fatigue, fever, anorexia, dark urine and abdominal pain