Chapter 39

Antibiotics Part 2

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 Multidrug-Resistant Organisms
 Organisms that are resistant to one or more
classes of antimicrobial drugs
 Methicillin-resistant Staphylococcus aureus
(MRSA)
 Vancomycin-resistant Enterococcus (VRE)
 Organisms producing extended-spectrum beta-
lactamases (ESBLs)
 Carbapenem-resistant Enterobacteriaceae
(CRE)

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Multidrug-Resistant Organisms (Cont.)
 MRSA
 Threat of MRSA becoming resistant to all
antibiotics currently available
 No longer seen just in hospitals; it has spread to
the community setting, and approximately 50%
of staphylococcal infections contracted in the
community involve MRSA

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Multidrug-Resistant Organisms (Cont.)
 VRE: usually seen in urinary tract infections
(UTIs)
 Newer antibiotics have been developed to
successfully treat VRE and MRSA.

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Multidrug-Resistant Organisms (Cont.)
 ESBL
 Organisms that produce ESBL are resistant to all
beta-lactam antibiotics and aztreonam.
 Can be treated only with carbapenems or sometimes
quinolones
 Use of carbapenems: resistance occurred; production
of carbapenemase, which renders all carbapenems
ineffective
 Tigecycline and colistimethate

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 Aminoglycosides
 Natural and semisynthetic
 Produced from Streptomyces spp.
 Poor oral absorption; no oral forms (exception:
neomycin)
 Very potent antibiotics with serious toxicities
 Bactericidal; prevent protein synthesis
 Kill mostly gram-negative bacteria; some
gram-positive bacteria

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 Aminoglycosides (Cont.)
 Gentamicin
 Neomycin (Neo-Fradin)
 Tobramycin (TOBI)
 Amikacin

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 Aminoglycosides: Indications
 Used to kill gram-negative bacteria, such as
Pseudomonas spp., Escherichia coli, Proteus
spp., Klebsiella spp., Serratia spp.
 Often used in combination with other antibiotics
for synergistic effects (beta-lactams or
vancomycin)
 Used for certain gram-positive infections that are
resistant to other antibiotics

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 Aminoglycosides: Indications (Cont.)
 Aminoglycosides are poorly absorbed through
the gastrointestinal (GI) tract and are given
parenterally.
 Can also be given via inhalation for treatment of
lung infections
 Exception: neomycin
 Given orally to decontaminate the GI tract before
surgical procedures
 Also used as an enema for this purpose
 Used to treat hepatic encephalopathy

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 Aminoglycosides:
Adverse Effects
 Cause serious toxicities
 Nephrotoxicity (renal damage)
 Ototoxicity (auditory impairment and vestibular
impairment [eighth cranial nerve])
 Must monitor drug levels to prevent toxicities
 Minimum inhibitory concentration (MIC)

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 Aminoglycosides:
Adverse Effects (Cont.)
 Therapeutic drug monitoring
 Ototoxicity and nephrotoxicity are the most significant
 Headache
 Paresthesia
 Fever
 Superinfections
 Vertigo
 Skin rash
 Dizziness

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 Aminoglycosides:
Therapeutic Drug Monitoring
 Serum levels measured to prevent toxicity
 Serum level needs to be at least eight times
higher than the MIC.
 Time-dependent killing
 Concentration-dependent killing
 Peak: highest drug levels for once-daily
regimens
 Trough: lowest to ensure adequate renal
clearance of the drug and avoid toxicity

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 Aminoglycosides:
Therapeutic Drug Monitoring (Cont.)
 Postantibiotic effects
 Resistance
 Drug interactions

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 Quinolones
 Also called fluoroquinolones
 Excellent oral absorption
 Absorption reduced by antacids
 Effective against gram-negative organisms and
some gram-positive organisms

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 Quinolones (Cont.)
 Ciprofloxacin (Cipro)
 Norfloxacin (Noroxin)
 Levofloxacin (Levaquin)
 Moxifloxacin (Avelox)
 Gemifloxacin (Factive)
 Delafloxacin (Baxdela)

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 Quinolones:
Mechanism of Action
 Bactericidal
 Alter DNA of bacteria, causing death
 Do not affect human DNA
 Used to treat S. aureus, Serratia marcescens,
and Mycobacterium fortuitum
 Bacterial resistance to quinolone antibiotics:
Pseudomonas aeruginosa, S. aureus,
Pneumococcus spp., Enterococcus spp., and
the broad Enterobacteriaceae family that
includes E. coli.
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 Quinolones: Indications
 Gram-negative bacteria such as Pseudomonas
spp.
 Complicated urinary tract, respiratory, bone and
joint, GI, skin, and sexually transmitted
infections
 Anthrax (ciprofloxacin)

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 Quinolones: Interactions
 Oral quinolones: antacids, calcium, magnesium,
iron, zinc preparations, or sucralfate
 Patients need to take the interacting drugs at
least 1 hour before or after taking quinolones.
 Dairy products
 Enteral tube feedings
 Probenecid
 Nitrofurantoin
 Oral anticoagulants

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 Audience Response System
Question #1
During intravenous (IV) quinolone therapy in an
88-year-old patient, which potential problem is of
most concern when assessing for adverse effects?

A. Hepatotoxicity
B. Rhabdomyolysis
C. Tendon rupture
D. Nephrotoxicity

NOTE: No input is required to proceed.

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 Answer to System Question #1
ANS: C

A black box warning is required by the U.S. Food

and Drug Administration for all quinolones because
of the increased risk of tendonitis and tendon
rupture with use of these drugs. This effect is more
common in older patients, patients with renal
failure, and patients receiving concurrent
glucocorticoid therapy (e.g., prednisone).

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 Quinolones: Adverse Effects
Body system Adverse effects

CNS Headache, dizziness, insomnia,

depression, restlessness, convulsions

GI Nausea, vomiting, diarrhea,

constipation, thrush, increased liver
function study results, others

Cardiac Prolonged QT interval

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 Quinolones: Adverse Effects (Cont.)
Body system Adverse effects

Integumentary Rash, pruritus, urticaria, flushing

Other Ruptured tendons,* tendonitis,* fever,

chills, blurred vision, tinnitus

*Black box warning: increased risk of

tendonitis and tendon rupture.

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 Miscellaneous Antibiotics
 Clindamycin (Cleocin)
 Linezolid (Zyvox)
 Metronidazole (Flagyl)
 Nitrofurantoin (Macrodantin, Furadantin)
 Quinupristin–dalfopristin (Synercid)
 Daptomycin (Cubicin)
 Vancomycin (Vancocin, Vancoled)
 Colistimethate (Coly-Mycin)
 Telavancin (Vibativ)
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 Miscellaneous Antibiotics (Cont.)
 Clindamycin (Cleocin)
 Used for chronic bone infections, genitourinary
infections, intraabdominal infections, other serious
infections
 May cause pseudomembranous colitis (also known as
antibiotic-associated colitis, Clostridium difficile
diarrhea, or C. difficile infection)
 Potential interaction with vecuronium

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 Miscellaneous Antibiotics (Cont.)
 Daptomycin (Cubicin)
 Only drug of the new class known as lipopeptides
 Mechanism of action is not completely known.
 Binds to gram-positive cells in a calcium-dependent
process and disrupts the cell membrane potential
 Used to treat complicated skin and soft tissue
infections caused by susceptible gram-positive
bacteria, including MRSA and VRE

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 Miscellaneous Antibiotics (Cont.)
 Colistimethate (Coly-Mycin)
 Polypeptide antibiotic that penetrates and disrupts the
bacterial membrane of susceptible strains of gram-
negative bacterial
 Commonly referred to as colistin
 Serious adverse effects
 Can cause acute respiratory failure when
administered by inhalation

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 Miscellaneous Antibiotics (Cont.)
 Dalbavancin (Dalvance)
 Lipoglycopeptide
 Similar to telavancin in that it is indicated for the
treatment of skin and skin structure infections caused
by susceptible gram-positive organisms
 Effective against MRSA
 Extremely long half-life and dosed once weekly
 Most common side effects include nausea, diarrhea,
and headache.

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 Miscellaneous Antibiotics (Cont.)
 Linezolid (Zyvox)
 New class: oxazolidinones
 Used to treat vancomycin-resistant Enterococcus
faecium (VREF, VRE), hospital-acquired, and skin
structure infections, including those with MRSA
 May cause hypotension, serotonin syndrome if taken
with selective serotonin reuptake inhibitors (SSRIs),
and reactions if taken with tyramine-containing foods

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 Audience Response System
Question #2
A patient is prescribed linezolid (Zyvox) to treat
hospital-acquired pneumonia. It is most important for
the nurse to determine if the patient is also taking
which medication?

A. A diuretic
B. An SSRI
C. A cardiac glycoside
D. A thyroid replacement drug
NOTE: No input is required to proceed.

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 Answer to System Question #2
ANS: B

Linezolid has the potential to strengthen the

vasopressor (prohypertensive) effects of various
vasopressive drugs such as dopamine by an unclear
mechanism. Also, there have been postmarketing
case reports of this drug causing serotonin
syndrome when used concurrently with serotonergic
drugs such as the SSRI antidepressants. It is
recommended that SSRIs be stopped while patients
are receiving linezolid therapy, if possible.
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 Miscellaneous Antibiotics
 Metronidazole (Flagyl)
 Used for anaerobic organisms
 Intraabdominal and gynecologic infections
 Protozoal infections
 Several drug interactions

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 Miscellaneous Antibiotics (Cont.)
 Nitrofurantoin (Macrodantin)
 Primarily used for UTIs (E. coli, S. aureus, Klebsiella
spp., Enterobacter spp.)
 Use carefully if renal function is impaired
 Drug concentrates in the urine
 May cause fatal hepatotoxicity

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 Miscellaneous Antibiotics (Cont.)
 Quinupristin–dalfopristin (Synercid)
 30:70 combination; works synergistically
 Used for bacteremia and infections caused by VRE
and for treatment of complicated skin and skin
structure infections caused by S. pyogenes and S.
aureus, including MRSA
 May cause arthralgias or myalgias

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 Telavancin (Vibativ)
 Lipoglycopeptide
 Treatment of skin and skin structure infections
and pneumonia from gram + organisms
 Adverse effects: renal toxicity, infusion-related
reactions, QT prolongation
 Newer drugs in this class:
 Dalbavancin (Dalvance)
 Oritavancin (Orbactiv)

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 Miscellaneous Antibiotics
 Vancomycin (Vancocin)
 Treatment of choice for MRSA and other gram-
positive infections
 Oral vancomycin is indicated for the treatment of
antibiotic-induced colitis (C. difficile) and for the
treatment of staphylococcal enterocolitis.
 Must monitor blood levels to ensure therapeutic levels
and prevent toxicity
 May cause ototoxicity and nephrotoxicity

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 Audience Response System
Question #3
A 58-year-old man is receiving vancomycin as part of the
treatment for a severe bone infection. After the infusion, he
begins to experience some itching and flushing of the neck, face,
and upper body. He reports no chills or difficulty breathing. What
should the nurse suspect?

A. An allergic reaction has occurred.

B. An anaphylactic reaction is about to occur.
C. The medication will not be effective for the bone infection.
D. The IV dose may have infused too quickly.

NOTE: No input is required to proceed.

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 Answer to System Question #3
ANS: D

These symptoms are know as red man syndrome and

may occur during or after an infusion of vancomycin.
This syndrome is characterized by flushing or itching
of the head, face, neck, and upper trunk area.
Symptoms can usually be alleviated by slowing the
rate of infusion to at least 1 hour. Red man syndrome
is bothersome but usually not harmful. Rapid infusions
may also cause hypotension.

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 Miscellaneous Antibiotics
 Vancomycin (Vancocin)
 Red man syndrome may occur
• Flushing or itching of head, neck, face, upper trunk
• Antihistamine may be ordered to reduce these effects.
 Additive neuromuscular blocking effects in patients
receiving neuromuscular blockers
 Should be infused over 60 minutes
 Rapid infusions may cause hypotension.

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 Nursing Implications
 Before beginning therapy, assess drug allergies;
hepatic, renal, and cardiac function; and other
laboratory study results.
 Be sure to obtain a 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.

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 Nursing Implications (Cont.)
 It is essential to obtain cultures from appropriate
sites before beginning antibiotic therapy.
 Instruct patients to take antibiotics exactly as
prescribed and for the length of time prescribed;
they should not stop taking the medication early
even if they feel better.

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 Nursing Implications (Cont.)
 Assess for signs and symptoms of
superinfection: fever, perineal itching, cough,
lethargy, or any unusual discharge
 For safety reasons, check the name of the
medication carefully because there are many
drugs that sound alike or have similar spellings.
 Each class of antibiotics has specific adverse
effects and drug interactions that must be
carefully assessed and monitored.

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 Audience Response System
Question #4
A group of office workers is concerned because a package
was opened that contained a white powder substance.
There is a concern that the white powder is anthrax. Which
drug does the nurse anticipate being prescribed for the
office workers?

A. Daptomycin (Cubicin)
B. Colistimethate (Coly-Mycin)
C. Ciprofloxacin (Cipro)
D. Quinupristin–dalfopristin (Synercid)

NOTE: No input is required to proceed.

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 Answer to System Question #4
ANS: C

Ciprofloxacin (Cipro) is the drug of choice for the

treatment of anthrax (infection with Bacillus
anthracis).

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 Nursing Implications
 Monitor for therapeutic effects:
 Improvement of signs and symptoms of infection
 Return to normal vital signs
 Negative culture and sensitivity tests
 Disappearance of fever, lethargy, drainage, and
redness
 Monitor for adverse reactions.

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