Antimicrobial

Agents
Topics:
❑ Classification of Antimicrobial Drugs
✔ Classification by Susceptible Organism
✔ Classification by Mechanism of Action

❑ Acquired Resistance to Antimicrobial Drugs

❑ Superinfection
❑ Nursing responsibilities
❑ Antibiotic Classifications
❑ Antifungal, Antiprotozoal and Antihelmenthics CM
Fiel 2
Basic Principles of Antimicrobial
Therapy

CM
Fiel
 “
Modern antimicrobial agents had their debut in the 1930s
and 1940s and have greatly reduced morbidity and
mortality from infection. As newer drugs are introduced, our
ability to fight infections increases even more. However,
despite impressive advances, continued progress is
needed. There remain organisms that respond poorly to
available drugs; there are effective drugs whose use is
limited by toxicity; and there is, because of evolving
microbial resistance (AMR), the constant threat that
currently effective antibiotics will be rendered useless.
CM
4 Fiel
 Antibiotic and
Antimicrobial drug are
used interchangeably.
However, be aware that
the formal definitions of
these words are not
identical.
CM
Fiel 5
an ANTIBIOTIC is a chemical that is
produced by one microbe and has
the ability to harm other microbes.
Under this definition, only those
compounds that are actually made
by microorganisms qualify as
antibiotics.

an ANTIMICROBIAL drug is defined

as any agent, natural or synthetic,
that has the ability to kill or
suppress microorganisms. Under
this definition, no distinction is
made between compounds CM
Fiel
produced by microbes and those 6
 From the perspective of
therapeutics, there is no
benefit to distinguishing
between drugs made by
microorganisms and drugs
made by chemists. Hence, the
current practice is to use the
terms antibiotic and
antimicrobial drug
interchangeably. CM
Fiel 7
Actions of Antimicrobial
Drugs
▸ The primary goal of antimicrobial therapy is to assist the body’s
defenses in eliminating a pathogen.
▸ Medications that accomplish this goal by killing bacteria are
called bacteriocidal.
▸ Some drugs do not kill the bacteria but instead slow their
growth, allowing the body’s natural defenses to eliminate the
microorganisms. These growth-slowing drugs are called
bacteriostatic. CM
Fiel 8
 Empiric Antimicrobial
Therapy
Empiric antimicrobial therapy is directed against an
anticipated and likely cause of infectious disease. It is
used when antimicrobials are given to a person before
the specific bacterium or fungus causing an infection is
known.

It is the initial antibiotic regimen started within 24 hours

of admission. 
antibiotic selection: using observations of the patient
(history, physical examination and laboratory test
results) along with past clinical experiences and the 9
Classification of
Antimicrobial Drugs

▸ Classification by Susceptible Organism

▸ Classification by Mechanism of Action

CM
Fiel 10
Classification by Susceptible Organism

CM
Fiel
11
Antibiotics differ widely in their
antimicrobial activity.

▸ Narrow-spectrum ▸ Broad-spectrum
antibiotics, are active antibiotics are active
against only a few against a wide variety
species of of microbes.
microorganisms.

CM
Fiel 12
 CM
Fiel
13
Classification by Mechanism of ActionCM
Fiel
14
The antimicrobial drugs fall into seven major groups based on
mechanism of action.

1. Inhibitors of cell wall synthesis

2. Drugs that disrupt the cell membrane
3. Bactericidal inhibitors of protein synthesis
4. Bacteriostatic inhibitors of protein synthesis
5. Drugs that interfere with synthesis or integrity of bacterial DNA
and RNA
6. Antimetabolites
7. Drugs that suppress viral replication
CM
Fiel 15
CM
Fiel
 Selection of an Effective
•
Antibiotic
Selecting an incorrect drug will delay proper treatment, giving the microorganisms more time to
invade.
• Prescribing ineffective antibiotics also promotes the development of resistance and may cause
unnecessary adverse effects in the patient.
• Ideally, laboratory tests should be conducted to identify the specific pathogen prior to beginning anti-
infective therapy. Laboratory tests may include examination of urine, stool, spinal fluid, sputum, blood,
or purulent drainage for microorganisms.
• Organisms isolated from the specimens are grown in the laboratory and identified. After identification,
the laboratory tests different antibiotics to determine which is most effective against the infecting
microorganism. This process of growing the pathogen and identifying the most effective antibiotic is
called culture and sensitivity (C&S) testing.
CM
Fiel
 ACQUIRED RESISTANCE TO
ANTIMICROBIAL DRUGS
Over time, an organism that had once been highly
sensitive to an antibiotic may become less
susceptible, or it may lose drug sensitivity entirely.
In some cases, resistance develops to several
drugs. Acquired resistance is of great concern in
that it can render currently effective drugs useless,
thereby creating a clinical crisis and a constant
need for new antimicrobial agents. As a rule,
antibiotic resistance is associated with extended
hospitalization, significant morbidity, and excess CM
mortality. Fiel 18
CM
Fiel 19
To answer this question, we need to recall
two aspects of microbial ecology: (1)
microbes secrete compounds that are toxic
to other microbes and (2) microbes within a
given ecologic niche (e.g., large intestine,
urogenital tract, skin) compete with each
other for available nutrients.
How Do
▸ Under drug-free conditions, the various Antibiotics
microbes in a given niche keep each
other in check.
Promote
▸ Furthermore, if none of these organisms Resistance?
is drug resistant, introduction of
antibiotics will be equally detrimental to
all members of the population and
therefore will not promote the growth of CM
Fiel 20
any individual microbe.
▸ However, if a drug-resistant organism is
present, antibiotics will create selection
pressure favoring its growth by killing off
sensitive organisms.
▸ In doing so, the drug will eliminate the
toxins they produce and will thereby
facilitate survival of the microbe that is drug
resistant. How Do
▸ Also, elimination of sensitive organisms will Antibiotics
remove competition for available nutrients,
thereby making conditions even more Promote
favorable for the resistant microbe to
flourish. Resistance?
▸ Hence, although drug resistance is of no
benefit to an organism when there are no
antibiotics present, when antibiotics are
CM
introduced, they create selection pressure
Fiel 21
favoring overgrowth of microbes that are
ALL antimicrobial drugs promote
the emergence of drug-resistant
organisms. However, some
agents are more likely to promote
Which
resistance than others. Because
Antibiotics
broad-spectrum antibiotics kill
Promote
more competing organisms than
Resistance?
do narrow-spectrum drugs,
broad-spectrum agents do the
most to facilitate emergence of
resistance.
CM
Fiel 22
During antibiotic therapy, a nurse should…

Monitor SUPERINFECTIONS
E valuate liver / renal functions
D iarrhea (GI DISTRESS:N/V/D/C), may be common, provide health teachings
I nform the patient to consult prior to taking other meds
C ultures prior to initial dose (ideally)
Ask about Allergy and alcohol is No - no
T each patient that antibiotic are to be taken on full course
E valuate cultures, temperature and lab results
CM
Fiel 23
SUPERINFECTION

Superinfection is a special
example of the emergence
of drug resistance. A
superinfection is defined
as a new infection that
appears during the course
of treatment for a primary
infection.
CM
Fiel
 SUPERINFECTION

It can occur in the

mouth, respiratory tract,
intestine, genitourinary • Fatigue or weakness
tract, • New
or skin. or increased heat, pain, redness
, swelling, or unusual drainage
in any area.
more common with • Development or worsening of
lesions or ulceration of
the use of broad- oral mucous membrane,
presence of a black furry
spectrum tongue.
CM
• New or increased episodes
antibiotics. of diarrhea and abdominal
Fiel
General Nursing
Responsibility
▸ Check for antibiotic allergy
▸ Administer antibiotics only as ordered
▸ Regularly check for organ toxicity
▸ Educate patients never to take antibiotics
without guidance
from a licensed doctor
CM
Fiel 26
 Antibiotic Classifications

Penicillins Cephalospor Macrolides

ins

Tetracyclines Aminoglycosi Flouroquinolone Sulfonamide

des s s
CM
Fiel 27
CM
Fiel
PENICILLIN Nomenclature: usually ends in “-cillins”
Known Drug: pen g (iv form), pen v (oral form),
amoxicillin
Action: bactericidal, inhibit cell wall
synthesis (beta-lactam ring)
Indication: most gram (+) and some gram (-)
bacteria
• Pneumonia, rti, uti, sti, some skin
infections
• Meningitis, GI infections due to salmonella
and shigella
Warnings: allergy to penicillin and
cephalosphorins, caution with renal and liver
failure
side effects: Nausea, vomiting, diarrhea
watch out for: allergy and superinfection,
haemolytic anemia CM
Note: bacterial evolution had enable some
Fiel
 Further Note:
PENICILLIN Broad-spectrum penicillins
(aminopenicillins)
• Prototype: amoxillin, ampicillin (se: rash,
pseudomembranous colitis)
Penicillinase-resistant penicillins
(antistaphyloccoal penicillins)
• Prototype: methicillin (se: interstitial
nephritis)
• Not used for mrsa
Extended-spectrum penicillins
(antipseudomonal penicllins)
• Used w/th clavunalic acid
• Ticarcillin , carbenicillin, pipercillin
Beta-lactamase inhibitors
• amoxicillin- clavulanic acid
•
CM
ampicillin-sulbactam (Unasyn),
• piperacillin-tazobactam (vigocid) Fiel
PENICILLIN
Drug interactions:
• may decrease the
effectiveness of oral
contraceptives
• IF mixed with an
aminoglycoside in IV solution,
the actions of both drugs are
inactivated.
CM
Fiel
Cephalosporin

CM
Fiel
 Nomenclature: usually STARTS in “Cef-”
CEPHALEXIN Known Drug: cephalexin, ceftriaxone
Action: bactericidal, inhibit cell wall
synthesis, resistant to beta-lactamase
Indication: gram (+) and (-) bacteria

1st gen – 2nd choice if (+) penicillin-allergy,

mostly gram (+) however often destroyed by
beta-lactamase (cephalexin, cefazolin)
2nd gen – usually gram (-) bacteria, most are
not affected by beta-lactamase (cefaclor,
cefoxitin, cefuroxime)
3rd gen and 4th gen - effective in treating
sepsis and many strains of gram-negativeCM
bacilli Fiel
CEPHALEXIN 3rd gen – cefixime, cefoxatime, ceftazidime,
ceftriaxone
4th gen – cefipime

WARNING: allergy to penicillin and

cephalosphorins
Side effects: GI disturbance (n/v/d)
• Increase in glucose values
• Anaphylaxis may occur
• Nephrotoxic
• Thromobocytopenia
Drug interactions: No-No to
alcohol (results to disulfram-reaction:
CM
flushing of the skin, accelerated heart rate, shortness
of breath, nausea, vomiting, throbbing headache, Fiel
CM
Fiel 35
*Methicillin-resistant Staphylococcus
aureus (MRSA) is a bacterium that causes
infections in different parts of the body.
MRSA infection is caused by a type of
staph bacteria that's become resistant to
many of the antibiotics used to treat
ordinary staph infections.

CM
Fiel 36
Macrolide CM
Fiel
MACROLIDE Nomenclature: has “-thromycin” but pls
remember ace
Known Drug: Azithromycin, Clarithromycin,
Erythromycin
Action: bacteriostatic, inhibit protein
synthesis
Indication: gram (+) and (-) bacteria
• mild to moderate RTI, INFECTION OF
sinuses, GI tract, skin and soft tissue,
diphtheria, impetigo contagiosa, and STI
Warnings: allergy to MACROLIDES caution
with renal and liver functions
side effects: Nausea, vomiting, diarrhea,
AnD CRAMPING, CM
POSSIBLY
Fiel
CONJUCTIVITIS (AZITH), arrhythmia
MACROLIDE
Watch for: signs of SUPERINFECTION

DRUG INTERACTION:
• can increase serum levels of theophylline
(bronchodilator),
• To avoid severe toxic effects,
erythromycin should not be used with
other macrolides
• Antacids may reduce azithromycin peak
levels when taken at the same time
CM
Fiel
CM
Fiel
LINCOSAMIDES
GLYCOPEPTIDES

Extended-Macrolide Group
CM
Fiel 41
 Nomenclature: NONE
EXTENDED-MACROLIDE GROUP: Known Drug: Clindamycin

LINCOSAMIDES Action: Bacteriostatic, inhibit RNA

TRANSLOCATION, may also have
bactericidal effect
Indication: ANAEROBIC INFECTIONS
ABOVE THE DIAPHRAGM
• Lung abscess
• Aspiration pneumonia
• Mrsa soft tissue infections
• Necrotizing fasciitis
• PID (Pelvic Inflammatory Disease)
Side effects: Nausea, vomiting,
stomatitis, rash
Adverse effects: colitis and anaphylactic
shock.
Drug interactions: incompatible CM with
aminophylline, phenytoin Fiel
(Dilantin),
 Nomenclature: NONE
EXTENDED-MACROLIDE GROUP: Known Drug: vancomycin

GLYCOPEPTIDES
Action: bactericidal, inhibit cell wall synthesis
Indication: gram (+) infections
• Antibiotic-associated pseudomembranous
caused by clostridium difficile and
staphylococcal enterocolitis
• used against drug-resistant S.aureus
• cardiac surgical prophylaxis for individuals
with penicillin allergies
• given IV for severe infections due to
MRSA; septicemia; and bone, skin, and
lower respiratory tract infections that do
not respond or are resistant to other
antibiotics.
Side effects: Nausea, vomiting, taste
alterations, “red-man syndrome”
Adverse effects: ototoxic, nephrotoxic,
thrombophlebitis CM
Drug interactions: not to be given Fiel
with
CM
Tetracyclin
Fiel
TETRACYCLINES Nomenclature: usually ends in “-
cycline”
Known Drug: doxycycline, tetracycline
Action: bactericiostatic, inhibit protein
synthesis
Indication: gram (+) aerobes and
anaearobes
Useful in skin infections, STIs,
Side effects: nausea, vomiting,
diarrhea, photosensitivity, dental
staining
Adverse effects: nephrotoxic,
superinfection CM
Not for: pregnant and lactating Fiel
moms
Aminoglycosides
CM
Fiel
AMINOGLYCLOSIDE
S Nomenclature: usually has “-mycin”
Known Drug: gentamycin,
streptomycin, amikacin
Action: bactericidal, inhibit protein
synthesis
Indication: serious gram (+) and (-)
infection
• Useful against MRSA
Side effects: nausea, vomiting,
tinnitus
Adverse effects: nephrotoxic,
CM
Fiel
ototoxic, neurotoxic, superinfection
Fluoroquinolon
es
CM
Fiel
 FLUOROQUINOLONES
Nomenclature: usually ends in “-floxacin”
Known Drug: ciprofloxacin, ofloxacin,
levofloxacin
Action: bactericidal, inhibit dna synthesis
Indication: SOME gram (+) and (-) infection
• Useful against UTI, BRONCHITIS, STI,
BONE, JOINT, OTIC AND OPTHALMIC
INFECTION
Side effects: nausea, vomiting,
diarrhea/constipation, photosensitivity,
rupture of achilles tendon
Adverse effects: nephrotoxic,
CM thrombophlebitis, superinfection
Fiel Not for: PREGNANT AND LACTATING
MOTHERS, PATIENT WITH MYASTHENIA
Sulfonamide
s
CM
Fiel
SULFONAMIDES Nomenclature: usually starts in “sulfa-”
Known Drug: sulfadiazine, trimethoprim-sulfa
methoxazole
Action: bactericiostatic, inhibit folic acid
synthesis
Indication: may be used as alternarive for
patients with penicillin allergy
• gram (+) and (-) infection
• Useful against UTI, rti, ear and GI infection
• used to prevent Pneumocystis carinii in
patients with AIDS
Side effects: nausea, vomiting, ANOREXIA,
ANEMIA, RASH, PHOTOSENSITIVY,
CRYSTALLURIA
CM Adverse effects: nephrotoxic, BLOOD
Fiel DYSCRASIA, STEVEN JOHNSONS’
SYNDROME
Antifungals and
Antiprotozoals

CM
Fiel
ANTIFUNGALS
• FUNGUS – ALSO KNOWN AS
DERMATOPHYTES
• MYCOSIS – INFECTION CAUSED BY
FUNGUS
• USUALLY AFFECT THE INTEGUMENTARY
SYSTEM
• CLASSIFIED IN 2 TYPES:
• OPPURTUNISTIC
• NONOPPURTUNISTIC

ANTIFUNGALS / ANTIMYCOTIC
• POLYENES (E.G., AMPHOTERICIN B,
NYSTATIN)
CM
• AZOLES (E.G., KETOCONAZOLE) Fiel
 POLYENES • NOMENCLATURE: NONE

AMPHOTERICIN B
• KNOWN DRUG: FUNGIZONE

• ACTION: FUNGICIDAL, BINDS TO THE

FUNGAL CELL MEMBRANE AND FORMING
OPEN CHANNELS THAT INCREASE CELL
PERMEABILITY AND LEAKAGE OF
INTRACELLULAR COMPONENTS
• INDICATION: SEVERE SYSTEMIC FUNGAL
INFECTION
• SIDE EFFECTS: FLUSH, FEVER, CHILLS,
NAUSEA, VOMITING, HYPOTENSION,
PARESTHESIAS AND THROMBOPHLEBITIS
CM
• ADVERSE EFFECTS: NEPHROTOXIC, Fiel
HYPOKALEMIA, HYPOMAGNESEMIA
POLYENES • NOMENCLATURE: NONE

NYSTATIN • KNOWN DRUG: MYCOSTATIN

• ACTION: FUNGISTATIC, FUNGICIDAL,
INCREASES PERMEABILITY OF THE
FUNGAL CELL MEMBRANE, THUS
CAUSING THE FUNGAL CELL TO
BECOME UNSTABLE AND TO
DISCHARGE ITS CONTENT.
• INDICATION: TOPICAL AND ORAL
TREATMENT FOR CANDIDA INFECTION
• SIDE EFFECTS: NAUSEA, VOMITING,
DIARRHEA, RASH CM
Fiel
• ADVERSE EFFECTS: HYPERSENSITIVITY
 • NOMENCLATURE: ENDS IN “-AZOLE”
AZOLE GROUP • KNOWN DRUG: KETOCONAZOLE,
METRONIDAZOLE, FLUCONAZOLE
• ACTION: FUNGICIDAL, INHIBIT
CYTOCHROME P450 IN FUNGAL
CELLS LEADING TO CELL LYSIS
• INDICATION: TOPICAL AND ORAL
TREATMENT FOR VARIOUS FUNGAL
INFECTIONS
• SIDE EFFECTS: NAUSEA, VOMITING,
CM DIARRHEA/CONSTIPATION,
Fiel DROWSINESS
 METRONIDAZOLE • DRUG CLASS: ANTIFUNGAL,
ANTIPROTOZOAL, AMOEBICIDE,
ANTIBACTERIAL
• ACTION: INHIBIT DNA SYNTHESIS
RESULTING TO CELL DEATH
• INDICATION: H. PYLORI INFECTION,
AMOEBIASIS, TRICHOMINIASIS,
FUNGAL INFECTIONS
• SIDE EFFECTS: NAUSEA, VOMITING,
DIARRHEA, UNPLEASANT METALLIC
TASTE
CM
Fiel • ADVERSE EFFECTS: HYPERSENSITIVITY,
BLOOD DYSCRASIAS, HEPATOTOXIC
 Antihelmenthics

CM
Fiel
ANTIHELMINTHS helminths – large organisms (parasitic
worms) that feed on host tissue.
helminthiasis – INFECTION CAUSED
BY helminths
• USUALLY AFFECT THE intestines
but may extend to the lymphatic
system, blood vessels and liver
Group of helminths
• cestodes (tapeworms)
• trematodes (flukes)
• intestinal nematodes (roundworms)
• tissue-invading nematodes (tissue
roundworms and filariae) CM
Fiel
ALBENDAZOLE
Nomenclature: NONE
Known Drug: ALBENDAZOLE (TAPE
WORM), MEBENDAZOLE (PIN WORM)
PRAZIQUANTEL (SCHISTOSOMIASIS)
PYRANTEL (ASCARIS)
Action: UNCLEAR BUT generally involves
interference with the integrity of parasite
cells, neuromuscular coordination, or
protective mechanisms against host
immunity, which lead to starvation,
paralysis, and expulsion or digestion of the
parasite.
Indication: HELMENTHIC INFECTION
Side effects: GI DISTRESS, POSSIBLY
DIZZINESS, WEAKNESS, HEADACHE, CM
DROWSINESS Fiel
61