Antibiotics, Antivirals

Barbara S. Hays, RN Winter 2006

Principles of antimicrobial therapy

Bactericidal agents: kill organisms Bacteriostatic agents: inhibit growth, usually by inhibiting protein synthesis

Antimicrobial therapy mechanisms of action

Inhibition of cell wall synthesis
Penicillins, Cephalosporins
Organism becomes osmotically unstable: lysis

Inhibition of protein synthesis

Aminoglycosides
Cause formation of abnormal proteins/inhibit synthesis by irreversible binding to ribosomal subunit

Disruption/alteration of membrane permeability

Antifungals
Bind to specific cell wall components Organism leaks cellular components

Antimicrobial therapy mechanisms of action, II

Inhibition of nucleic acid synthesis (RNA/DNA)
Antivirals

Inhibition of specific biochemical pathways

Bacteriostatic agents Competitively inhibit metabolic pathways that are critical to survival of the organism

Selection of antibiotics
Sometimes broad spectrum antibiotics before Culture/Sensitivity (C&S) results Once results in: change to least toxic antibiotic to which organism is sensitive Gram stain
Positive (holds purple stain)
Also see if cocci, rods, etc

Negative (takes red counterstain)

Selection of antibiotics
Combination therapy
When synergistic effect desired When development of resistance is a problem, like with TB When nature of infection is not known [or multiple, mixed organisms]

Administration of antibiotics
Oral
Unpleasant taste GI upset Client may stop taking when begins to feel better relapse and resistance a concern

Intramuscular
Painful/irritating (may mix with lidocaine) Rotate injection sites Avoid in shock/hypoperfusion states [vancomycin IM causes tissue necrosis]

Administration of antibiotics
Intravenous (requires the most nsg care)
When high concentrations must reach site When client unable to take oral meds, or if oral absorption is poor When antibiotic of choice is only available in this form

Nursing implications
Accurate/timely administration is a must
Inadequate response Development of resistant organisms

Drug imcompatibilities Phlebitis

General side/adverse effects of antimibrobials

Allergic reactions
Generalized rash to life-threatening anaphylactic shock
Rashes: mild antihistamines (or tolerate it) Anaphylactic reactions
Hypotension Cardiovascular collapse Bronchoconstriction Laryngospasm

General side/adverse effects of antimibrobials

Superinfections/opportunistic infections
Normal flora altered
Buttermilk, live cultured yogurt

Some resistant to current antibiotic flourish

Other
Fluid/electrolyte (many are sodium salts)
Fluid retention, CHF

GI upsets (n/v/d)

Antibiotic use during pregnancy

All antimicrobials cross placenta to some degree. May be teratogenic (not much literature, so physicians are careful) Tetracyclines
Disrupt tooth/bone formation in fetus

Antibiotic use in children and the elderly

Children
Absorption, distribution, metabolism and excretion issues Elimination dependent on health of kidneys Immature liver of neonate may be unable to inactivate the medication

Elderly
Similar to very young because of diminished functions

Aminoglycosides (Easy p 473)

Gentamycin/Garamycin prototype (p 474)
Bactericidal against gram negative, gram positive, myocbacteria [TB, Leprosy], and protozoans Poorly absorbed [gut active, esp. neomycin] so given IV or IM Penicillin assists to transport across cell membrane Toxic (so peak/trough levels)
Kidneys (if doesnt drop below 2mcg/ml) keep well hydrated and watch BUN/creatinine levels Nerves 8th cranial nerve: hearing (if rises above 12 mcg/ml) Allergic reactions, anaphylaxsis agranulocytosis

Penicillins (Easy p 477)

Natural penicillins (Prototype p 479). Mold.
About all there was during WWII
Then most staph was susceptible to PCN. Now over 90% of the strains are resistant to PCN.

Penicillinase Penicillinase-resistant penicillins

Methcillin, Staphcillin, Unapen [MRSA can live on your hands for three hours]

Aminopenicillins
Ampicillin, Unasyn (may cause nephritis, agranulocytosis)

Extended spectrum penicillins

Ticarcillin, Pipercillin

Penicillins (Easy p 479, 480)

Drug interactions
Probenecid increases plasma concentration by competing for excretion by kidneys Decreased effectiveness of hormonal contraceptives Large doses can cause bleeding High doses inactivate aminoglycosides (while lower doses help)

Penicillins (Easy p 480)

Adverse reactions
Hypersensitivity
Rash to anaphylactic shock

GI upset
Tongue inflammation (stomatitis, glossitis) n/v/d

Liver toxicity by Oxacillin

Cephalosporins (Easy p 482)

Derived from fungus, structurally similar to PCNs Divided into generations based on spectrums of activity, typically broader with each generation
First generation Second generation Third generation Fourth generation

Cephalosporins
Things to consider (p 486)
Antabuse-like reaction up to 72 hours after dose Increased risk of bleeding with some
Risk of cross-allergy to those sensitive to PCNs

Tetracyclines (Easy p 489)

Prototype: p 490
Tetracycline HCl (Achromycin) Vibramycin Aureomycin

Work well for acne, respiratory infections, syphilis (but bacteria may become resistant) Absorption reduced with milk, antacids, calcium

Tetracyclines
Adverse reactions (p 491)
Superinfection GI upset
Stomatitis, black hairy tongue n/v/d

Photosensitivity Hepatic toxicity Renal toxicity Affects forming teeth/bones

Macrolides (Easy p 495)

Erythromycin
Acid sensitive (so need enteric coating) Cross BBB only with inflammation Effective for those with PCN allergy Use for Chlamydia [Ilotycin for neonates]

Adverse effects (see p 497)

Vancomycin (Easy p 498)

Used for treating MRSA
Adverse reactions (p 499)
Hypersensitivity/anaphylaxsis red man syndrome Neutropenia Hearing loss (temporary/permanent)

VREs [can live on surfaces for weeks!]

Fluoroquinolones [quinolones] (Easy p 507)

Used frequently in urinary tract infections Synthetic, broad spectrum Slow microbial resistance Food/dairy products reduce absorption Family members
Cipro (ciprofloxacin) Levaquin (levofloxacin) [NegGram (naladixic acid)] Floxin (ofloxacin)

Fluoroquinolones [quinolones]
Interact with many medications GI upset Compete with probenecid for excretion in the kidneys (go over client teaching p 509)

Sulfonamides (Easy p 510)

Prototype pro p 511 [Septra/Bactrim] Used for UTIs, ear infection, newborn eye prophylaxsis Give on empty stomach with full glass of water
Cause crystalluria and subsequent stone formation (client to drink 2-3 quarts/day)

Sulfonamides
Adverse reactions (p 511)
Urine crystals Hypersensitivity/allergy Increased effects of oral hypoglycemic agents

Antitubercular (Easy p 540 545)

Tuberculosis: on the rise again
Droplet spread Already tough to treat, is becoming more and more resistant

Currently recommending 4-fold attack (p 540). Bring out the big guns. In combination.
Isoniazid (INH) Rifampin [also used for severe, resistant infections] Pyrazinamide Streptomycin or ethambutol

Client non-compliance
Long term therapy, expense (6-9-12 months) DOT therapy (directly observe client taking the med)

Antitubercular meds
Side effects/adverse effects to consider
INH
Peripheral neuropathy hepatotoxicity

INH and Ethambutol

Visual disturbances

Streptomycin
Ears kidneys

Antifungal drugs (Easy p 545)

Go over p 546 and put in names
Clotrimazole (GYNe-Lotrimin, Mycelex) Grisofulvin (Fulvicin) Miconazole (Monistat)

Polyenes (Easy p 545)

Amphoteracin B [ampho-terrible B and Diflucan p 554] Nystatin (Mycostatin) -- topical

(esp. Amphoteracin B) drug interactions (p 547)

Serious interactions with many drugs Kidney toxicity Produces hypokalemia (as do steroids and extended release PCNs. Watch for digitalis toxicity!)

Diflucan (p 554)
Much like amphoteracin B Drug interactions (p 555)

Antivirals (Easy p 516 539)

Acyclovir/Zovirax (prototype pro p 517)
Disrupts viral replication

Used to treat
genital herpes, simplex II Shingles (chickenpox virus) CytoMegal Virus (CMV) in those immunocompromized with AIDS

Adverse reactions (p 518)

Antivirals
[Relenza (zanamvir)]
Funky powder to inhale Does not permit release of newly formed viruses from surface of infected cells Works for flu A and B

Antivirals
Ribavirin (Easy p 522 526
Inhaled gives high concentrations in lungs Good for children with RSV
(of course you remember about children, viral illnesses, ASA, and Reyes Syndrome)

Antivirals to treat advanced HIV

Retrovir (AZT) to treat AIDS
IV to prevent transmission to fetus

Combination therapy works best Go over adverse reactions p 531 Teaching (go over p 531)