Chapter 27

Antituberculars, Antifungals,
and Antivirals

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 Tuberculosis
 Etiology
 Mycobacterium tuberculosis
• Acid-fast bacillus
 Transmission
 Person to person via droplets
• Coughing, sneezing, talking
 Patients at risk
 Immunocompromised
 Living or working in high-risk residential settings
 Injecting illegal drugs
 Health care workers with high-risk patients

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Mycobacterium tuberculosis

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Progression of TB Bacteria

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TB Bacillus (Acid-Fast & Aerobic)

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Pulmonary TB Nodules

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 Tuberculosis (Cont.)
 Symptoms
 Cough, fever, night sweats
 GI distress, weight loss
 Positive acid-fast bacilli in the sputum or bloody
sputum
 Prophylaxis recommended for those with:
 Close contact with active TB patient
 HIV positive/immunosuppressed
 Conversion from negative to positive TB
 Latent TB infection
 Injection drug users
 Recent immigrant from high-prevalence country
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TB Tx Options

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 Antitubercular Drugs
 Drug combinations
 Single-drug therapy
• Ineffective
 Multidrug therapy
• Decreases bacterial resistance to drug
• Treatment duration decreased

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 Antitubercular Drugs (Cont.)
 Drug selection
 First-line drugs
• Isoniazid, rifampin, rifabutin, rifapentine, pyrazinamide,
ethambutol
• More effective and less toxic than second-line
 Combination therapy
 Minimum of 3-5 drugs
 Initial phase
• Lasts 2 months
 Continuation phase
• Next 4-7 months

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 Antitubercular Drugs (Cont.)
 Treatment regimen
 Divided into 2 phases
 Phase 1
• Duration: 2 months
 Phase 2
• Duration: 4-7 months

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 Antitubercular Drugs (Cont.)
 Side effects and adverse reactions
 Headaches, dizziness, confusion
 GI distress, peripheral neuropathy
 Ocular toxicity, ototoxicity, nephrotoxicity,
hepatotoxicity
 Thrombocytopenia
 Respiratory depression
 Rifampin: turns body fluids orange
• Soft contact lens may be permanently discolored
 Pyridoxine (vitamin B6): hyperglycemia,
hyperkalemia, hypophosphatemia, and hypocalcemia

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 Antitubercular Drugs (Cont.)
 Isoniazid (INH)
 Route: Oral, IM
 Inhibits bacterial cell wall synthesis
 Side effects/adverse reactions
• Dry mouth, GI distress, constipation
• Blurred vision, photosensitivity, tinnitus
• Drowsiness, dizziness, peripheral neuropathy
• Psychotic behavior, tremors, seizures
• Hyperglycemia, hepatotoxicity
• Thrombocytopenia, agranulocytosis

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 Tuberculosis in
Special Populations
 Special populations
 Pregnancy
 HIV
 Pediatrics
 CDC link

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 Nursing Process: Antitubercular
Drugs
 Assessment
 Obtain a general medical history from the patient.
 Assess for hearing changes if drug regimen includes
streptomycin.
 Nursing diagnoses
 Knowledge, Deficient related to unfamiliarity with
medications.
 Planning
 The patient’s sputum test for acid-fast bacilli will be
negative 2-3 months after prescribed antitubercular
therapy.
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 Nursing Process: Antitubercular
Drugs (Cont.)
 Nursing interventions
 Administer INH 1 hour before or 2 hours after meals.
 Give pyridoxine (vitamin B6) as prescribed with INH to
prevent peripheral neuropathy.
 Monitor hepatic function tests.
 Emphasize importance of complying with drug
regimen.
 Evaluation

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 Fungal Infections
 Fungal infections (candidiasis)
 Local infections
• Mucous membranes, hair, nails, and moist skin areas
• Mild
• Examples: Oral candidiasis or thrush, Vaginal candidiasis
 Systemic infections
• Severe
• Affects lungs, abdomen, central nervous system

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 Fungal Infections (Cont.)
 Classifications
 Opportunistic infections
• Candidiasis, aspergillosis, mucormycosis, pneumocystis
pneumonia
• Usually occur in immunocompromised or debilitated
population, or those taking antibiotics, corticosteroids,
chemotherapy, or other immunosuppressives
 Primary infections
• Blastomycosis, histoplasmosis, coccidioidomycosis,
cryptococcosis, and paracoccidioidomycosis

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 Antifungal Drugs
 Antifungal drug groups (antimycotic drugs)
 Polyenes
• Amphotericin B, nystatin
 Azoles
• Fluconazole
 Antimetabolic
• Flucytosine
 Echinocandins
• Caspofungin

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 Polyenes
 Amphotericin B
 Treats severe, systemic fungal infections
 Action
• Binds to fungal cell membranes, causing cell permeability,
and leakage of cellular contents
 Side effects/adverse reactions
• Flushing, fever, chills, headache, tachypnea
• Dizziness, hypotension, GI distress
• Paresthesia, thrombophlebitis
• High doses: nephrotoxicity, hypokalemia, hypomagnesemia
• Reactions usually begin 1-3 hours after initiating drug
• Avoid reactions: pretreat 30-60 minutes before drug with:
 Acetaminophen, diphenhydramine, hydrocortisone

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 Polyenes (Cont.)
 Nystatin (Mycostatin)
 Methods of administration
• Oral, topical
 Action
• Binds to sterols causing loss of intracellular potassium and
other cell contents
 Side effects
• Skin irritation, rash, pruritus
• GI distress
• Hyperglycemia, tachycardia
• Angioedema, bronchospasm
• Stevens-Johnson syndrome

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 Azoles
 Azoles
 Route
• Oral, IV, vaginal, topical
 Action
• Increases permeability of fungal cell membrane by inhibiting
ergosterol synthesis
 Side effects
• Headache, rash
• GI distress
• Hypokalemia, dysrhythmias
• Hepatotoxicity, nephrotoxicity

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 Antimetabolites
 Antimetabolites
 Action
• Selectively penetrating the fungal cell which disrupts fungal
DNA and RNA synthesis
 Well-absorbed from the GI tract
 Used in combination with other antifungals such as
amphotericin
 Side effects
• Renal and hepatic impairment

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 Echinocandins
 Echinocandins
 Route
• IV
 Action
• Inhibits biosynthesis of essential components of fungal cell
wall which interferes with growth and reproduction of
Candida and Aspergillus species
 Side effects
• Injection site reaction
• Elevated hepatic enzymes
• Histamine-mediated reactions

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 Nursing Process: Antifungals
 Assessment
 Assess patient’s hepatic and renal function tests.
 Nursing diagnoses
 Knowledge, Deficient related to the treatment
regimen.
 Planning
 The patient’s fungal infection will be resolved without
life-threatening adverse reactions.

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 Nursing Process: Antifungals (Cont.)
 Nursing interventions
 Advise the patient to take drugs as prescribed.
 Advise the patient not to consume alcohol.
 Encourage the patient to report side effects.
 Evaluation

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 Viruses
 Viruses
 Method of transmission
• Droplets: coughing, sneezing, talking
 Process of replication of itself
 Common viral infections
• Influenza, herpes, hepatitis

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Viruses (Image)

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 Influenza
 Influenza (flu)
 Highly contagious
 Affects nose, throat, lungs
 Seasonal, more prevalent from fall to spring
 Antigen types
• Influenza A
 Moderate to severe viral infection
• Influenza B
 Mild viral infection
• Influenza C
 Mild respiratory, viral infection

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 Influenza (Cont.)
 Influenza (flu)
 Signs and symptoms
• High fever, headache
• Fatigue, weakness, myalgia
• Watery nasal discharge
• Red watery eyes
• Photophobia
• Chills, sore throat, nonproductive cough

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 Herpes Viruses
 Herpes simplex virus type 1 (HSV-1)
 Causes with cold sores
 Herpes simplex virus type 2 (HSV-2)
 Causes lesions on genitalia
 Varicella-zoster viruses (HSV-3 or VZV)
 Causes chickenpox and shingles
 Epstein-Barr virus (HHV-4 or EBV)
 Causes mononucleosis
 Cytomegalovirus (HHV-5 or CMV)
 Causes weakened immune system

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 Hepatitis
 Hepatitis virus
 Serious liver infection
 Transmission
• Needlestick, intimate sexual contact, or childbirth
 Bloodborne pathogens spread via blood and body
fluids
 Signs and symptoms
• Fatigue, malaise
• Nausea, abdominal pain
• Jaundice

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 Non-HIV Antivirals
 Non-HIV antivirals
 Prevent or delay spread of viral infection
 Action
• Inhibits viral replication
 Influenza antivirals
 Decrease viral spread
 Shorten duration of signs and symptoms
 Side effects
• Dizziness, headache, insomnia, fatigue
• GI distress, abnormal behavior

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 Non-HIV Antivirals (Cont.)
 Herpes simplex antivirals
 Action
• Interferes with DNA synthesis
 Cytomegalovirus antivirals
 Use—CMV retinitis in people with AIDS
 Action
• Inhibits DNA polymerase to suppress viral replication
 Side effects
• Headache, dizziness, GI distress
• Rash, pruritus, hematuria
• Leukopenia, thrombocytopenia, granulocytopenia

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 Non-HIV Antivirals (Cont.)
 Hepatitis antivirals
 Delay progression of liver disease.
 Do not discontinue abruptly or exacerbations can
occur.
 Action
• Inhibit viral replication
 Side effects—Mild to life-threatening
• Fatigue, flu-like symptoms, depression
• Alopecia, anorexia, dysgeusia, arthralgia, myalgia
• Thyroid and ophthalmic dysfunction
• Hepatotoxicity, renal impairment, infection

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 Nursing Process: Antiviral:
Acyclovir
 Assessment
 Obtain patient’s medical history including hepatic and
renal disease.
 Nursing diagnoses
 Knowledge, Deficient related to inexperience with
antiviral medications.
 Planning
 The patient’s signs and symptoms of the viral
infection will be diminished or eliminated.

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 Nursing Process: Antifungals
 Nursing interventions
 Observe the patient for evidence of side effects.
 Check the patient for superinfections.
 Monitor the patient’s CBC for evidence of leukopenia,
thrombocytopenia, low hemoglobin, and hematocrit.
 Evaluation

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 Practice Question #1
Which teaching for the patient who is taking
fluconazole is a priority for the nurse?

A. Take concurrent vitamin B6 to prevent peripheral

neuropathy.
B. Take 1 hour before or 2 hours after meals.
C. Advise that hypoglycemia may occur with concurrent
oral sulfonylureas.
D. Warn that gingival hyperplasia may occur with
prolonged use.

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 Practice Question #2
A patient has developed active tuberculosis and is
prescribed isoniazid and rifampin. Which information
will the nurse include in teaching the patient about
taking this drug? (Select all that apply.)

A. Isoniazid should be given 1 hour before or 2 hours after

meals.
B. Have periodic eye examinations as ordered by the health
care provider.
C. Compliance with drug regimen is essential.
D. Report numbness, tingling, and burning of hands and feet.
E. Warn patient that rifampin may turn body fluids a
harmless green color.
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 Practice Question #3
A middle-aged adult is diagnosed with
tuberculosis. Which is true of treatment for this
diagnosis?

A. Treatment may take about 10 days to 2 weeks.

B. Usually two to three agents are needed.
C. The bacteria is usually resistant to treatment therapy.
D. Treatment for tuberculosis is usually without side
effects.

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 Practice Question #4
When teaching a patient about isoniazid (INH) and
rifampin drug therapy, which statement will the
nurse include?

A. “Take isoniazid with meals.”

B. “Double the amount of vitamin C in your diet to prevent
the peripheral neuropathy associated with isoniazid
therapy.”
C. “Notify the primary health care provider immediately if
your urine turns a red-orange color.”
D. “Avoid exposure to direct sunlight.”
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 Practice Question #5
A patient is diagnosed with a Candida infection in
the mouth. The nurse anticipates that the patient
will be treated with

A. metronidazole.
B. amphotericin B.
C. isoniazid.
D. nystatin.

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 Practice Question #6
When caring for a patient receiving amphotericin
B, it is most important for the nurse to assess the
patient for the development of

A. hypokalemia.
B. hypernatremia.
C. hypocalcemia.
D. hypermagnesemia.

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 Practice Question #7
Which nursing intervention is the priority when a
patient is receiving antiviral drugs?

A. Promoting hydration
B. Enhancing bowel function
C. Increasing tidal volume
D. Promoting circulation

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