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Pharmacology for Nurses: A Pathophysiologic Approach, Third EditionAdams • Holland
CHAPTERCHAPTER
Pharmacology for NursesA Pathophysiologic Approach
Third Edition
Drugs for Bacterial Infection
34
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Pathogens
• Organisms that can cause disease• Must bypass the body’s defenses
– Bacteria, viruses– Fungi; intracellular organisms– Multicellular animals
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Pathogens (continued)
• Cause disease in two ways– Invasiveness: divide rapidly to overcome and
cause direct damage– Toxins: very small amounts disrupt normal
cell function
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Pathogenicity and Virulence
• Pathogenicity: ability of organism to cause infection
• Virulence: ability of a microbe to produce disease when present in minute numbers
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Methods of Describing Bacteria
• Basic Shapes– Bacilli- rod shape– Cocci-spherical– Spirilla-spiral shape
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Methods of Describing Bacteria (continued)
• Ability to use oxygen– Aerobic- with O2
– Anaerobic- without O2
• Staining Characteristics– Gram positive– Gram negative
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Anti-infective Drugs
• Known as antibacterial, antimicrobial, antibiotic
• Classified by– Chemical structures (e.g., aminoglycoside,
Fluoroquinolone)– Mechanism of action (e.g., cell-wall inhibitor,
folic-acid inhibitor)– See Table 34.1, Bacterial Pathogens and
Disorders
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Pharmacology for Nurses: A Pathophysiologic Approach, Third EditionAdams • Holland
Action of Anti-infective Drugs
• Affect target organism’s structure, metabolism, or life cycle
• Goal is to eliminate pathogen– Bactericidal – kill bacteria– Bacteriostatic – slow growth of bacteria
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Figure 34.1 Mechanisms of action of antimicrobial drugs
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Acquired Resistance
• Occurs when pathogen acquires gene for bacterial resistance– Through maturation
Antibiotics destroy sensitive bacteria Insensitive (mutated) bacteria remain
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Acquired Resistance (continued)
• Mutation random, occur during cell division• Mutated bacteria multiply• Antibiotics do not create mutations• By another microbe
– Bacteria passed to others
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Widespread Use of antibiotics
• Resistance not caused by but is worsened by overprescription of antibiotics– Results in loss of antibiotic effectiveness
• Only prescribe when necessary• Long-time use increases resistant strains
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Widespread Use of antibiotics (continued)
• Nosocomial infections often resistant• Prophylactic use sometimes appropriate• Nurse should instruct client to take full
dose
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Figure 34.2 Acquired resistance
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Role of the Nurse
• Monitor client’s condition• Provide client education• Obtain medical, surgical, and drug history• Assess lifestyle and dietary habits• Obtain description of symptomology and
current therapies
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Role of the Nurse (continued)
• Obtain specimens for culture and sensitivity prior to start of therapy
• Monitor for indication of response to therapy– Reduced fever– Normal white blood count– Improved appetite– Absence of symptoms such as cough
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Role of the Nurse (continued)
• After parenteral administration, observe closely for possible allergic reactions
• Monitor for superinfections– Replace natural colon flora with probiotic
supplements or cultured diary products
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Role of the Nurse (continued)
• Teach clients to– Wear medic-alert bracelets if allergic to
antibiotics– Report symptoms of allergic reaction– Not stop taking drug until complete
prescription has been taken
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Drug Therapy with Penicillin
• Assess previous drug reactions to penicillin
• Avoid cephalosporins if client has history of severe penicillin allergy
• Monitor for hyperkalemia and hypernatremia
• Monitor cardiac status, including ECG changes
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Penicillin
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Penicillin
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Cephalosporin Therapy
• Assess for presence or history of bleeding disorders– Cephalosporins may reduce prothrombin
levels
• Assess renal and hepatic function• Avoid alcohol
– Some cephalosporins cause disulfiram (Antabuse)-like reaction with alcohol
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Tetracycline Therapy
• Contraindicated for clients who are pregnant or lactating– Effect on linear skeletal growth of fetus and
child
• Contraindicated in children less than 8 years of age– Permanent mottling and discoloration of teeth
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Tetracycline Therapy (continued)
• Tetracycline decrease effectiveness of oral contraceptives– Alternate birth-control method should be used
while taking medication
• Use caution in clients with impaired kidney or liver function
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Tetracycline Therapy (continued)
• Photosensitivity may result• Do not take with milk products, iron
supplements, magnesium-containing laxatives, or antacids
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Macrolide Therapy
• Assess presence of respiratory infection• Examine client for history of cardiac
disorders• Monitor hepatic enzymes with certain
macrolides, such as erythromycin estolate• Multiple-drug-drug interactions occur with
macrolides
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Aminoglycoside Therapy
• Monitor for ototoxicity and nephrotoxicity• Hearing loss may occur after therapy has
been completed• Neuromuscular function may also be
impaired• Increase fluid intake, unless otherwise
contraindicated, to promote excretion
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Fluoroquinolone Therapy
• Monitor white blood count• Monitor client with liver and renal
dysfunction• Teach that drugs may cause dizziness and
lightheadedness– Advise against driving or performing
hazardous tasks during drug therapy
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Fluoroquinolone Therapy (continued)
• Norfloxacin (Noroxin) may cause photophobia
• Teach that drug may affect tendons, especially in children
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Sulfonamide Therapy
• Assess for anemia or other hematological disorders
• Assess renal function; sulfonamides may increase risk of crystalluria
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Sulfonamide Therapy (continued)
• Contraindicated in clients with history of hypersensitivity to sulfonamides– Can induce skin abnormality called Stevens-
Johnson syndrome
• Teach clients how to decrease effects of photosensitivity
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Selection of an Antibiotic
• Careful selection of correct antibiotic – essential– Use of culture and sensitivity testing– For effective pharmacotherapy; to limit
adverse effects
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Selection of an Antibiotic (continued)
• Broad spectrum antibiotics– Effective for a wide variety of bacteria
• Narrow spectrum antibiotics– Effective for narrow group of bacteria
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Culture and Sensitivity Testing
• Examination of specimen for microorganisms
• Grown in Lab and identified• Tested for sensitivity to different antibiotics
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Culture and Sensitivity Testing (continued)
• Bacteria may take several days to identify• Viruses may take several weeks to identify• Broad spectrum antibiotics may be started
before lab culture completed
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Multidrug Therapy
• Affected by antagonism-combining two drugs may decrease efficacy of each
• Use of multiple antibiotics increases risk of resistance
• Multidrug therapy can be used– When multi-organisms cause infection– For treatment of tuberculosis– For treatment of HIV
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Superinfections
• Secondary infections that occur when too many host flora are killed by an antibiotic– Host flora prevent growth of pathogenic
organisms
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Superinfections (continued)
• Pathogenic microorganisms have chance to multiply – Opportunistic- take advantage of suppressed
immune system– Signs and symptoms include diarrhea,
bladder pain, painful urination, or abnormal vaginal discharge
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Host Factors Influence Choice of Antibiotics
• Host Factors Influence Choice of Antibiotics
• Immune system status• Local condition at infection site• Allergic reactions• Age• Pregnancy• Genetics
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Penicillin
• Prototype drug: penicillin G (Pentids)• Mechanism of action: to kill bacteria by
disrupting their cell walls• Primary use: as a drug of choice against
streptococci, pneumococci, and staphylococci organisms that do not produce penicillinase– Also medication of choice for gonorrhea and
syphilis
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Penicillin (continued)
• Adverse effects: diarrhea, nausea, vomiting, superinfections, anaphylaxis
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Cephalosporins
• Prototype drug: cefotaxime (Claforan)• Mechanism of action: to act with broad
spectrum activity against gram-negative organisms
• Primary use: for serious infections of lower respiratory tract, central nervous system, genitourinary system, bones, blood and joints
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Cephalosporins (continued)
• Adverse effects: hypersensitivity, anaphylaxis diarrhea, vomiting, nausea, pain at injection site
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Tetracycline
• Prototype drug: tetracycline HCL (Achromycin, others)
• Mechanism of action: effective against broad range of gram-positive and gram-negative organisms
• Primary use: clamydiae, rickettsiae, and mycoplasma
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Tetracycline (continued)
• Adverse effects: superinfections, nausea, vomiting, diarrhea, discoloration of teeth, photosensitivity
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Macrolide
• Prototype drug: erythromycin (E-Mycin, Erythrocin)
• Mechanism of action: to act as spectrum similar to that of penicillins – Also effective against gram-positive bacteria
• Primary use: for Bordetella pertusis (whooping cough) and Corynebacterium diphtheriae, most gram-positive bacteria
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Macrolide (continued)
• Adverse effects: nausea, abdominal cramping and vomiting, diarrhea– Most severe is hepatotoxicity
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Aminoglycoside
• Prototype drug: gentamycin (Garamycin)
• Mechanism of action: to act as broad-spectrum, bacteriocidal antibiotic
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Macrolide
• Primary use: for serious urinary, respiratory, nervous, or GI infections– Often used in combination with other
antibiotics– Used parenterally or as drops (Genoptic) for
eye infections
• Adverse effects: ototoxiciy, and nephrotoxicity
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Fluoroquinolone
• Prototype drug: ciprofloxacin (Cipro)• Mechanism of action: to inhibit bacterial
DNA gyrase– Affects bacterial replication and DNA repair
• Primary use: for respiratory infections, bone and joint infections, GI infections, ophthalmic infections, sinusitis, and prostatitis
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Fluoroquinolone (continued)
• Adverse effects: nausea, vomiting, diarrhea, phototoxicity, headache, dizziness
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Sulfonamide
• Prototype drug: trimethoprim-sulfamethoxazole (Bactrim, Septra)
• Mechanism of action: to kill bacteria by inhibiting bacterial metabolism of folic acid
• Primary use: for urinary tract infections, Pneumocystis carinii pneumonia, shigella infections of small bowel, and acute episodes of chronic bronchitis
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Sulfonamide (continued)
• Adverse effects: skin rashes, nausea, vomiting, agranulocytosis or thrombocytopenia
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Miscellaneous
• Clindamycin (Cleocin): for oral infections caused by bacteroides– Associated with pseudomembraneous colitis– Metronidazole (Flagyl) used to treat H. Pylori
infections of stomach
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Miscellaneous (continued)
• Vancomycin (Vancocin) effective for MRSA infections– Adverse effects: ototoxicity, nephrotoxicity,
red man syndrome
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Miscellaneous - new
• Oxazolidinones: linezolid (Zyvox) – as effective as vancomycin against MRSA
• Cyclic lipopeptides: daptomycin (Cubicin)- used to treat serious skin infections
• Carbapenems: imipenem (Primaxin) have some of the broadest spectrums
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Miscellaneous – new (continued)
• Ketolides: telithromycin (Ketek) –used for respiratory infections
• Glycylcyclines: tigecycline (Tygacil) used for drug-resistant abdominal infections and complicated skin infections
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Patients Receiving Antibacterial Therapy
• Assessment– Obtain complete health history—allergies,
drugs, drug interactions– Obtain specimens for culture and sensitivity
before initiating therapy– Perform infection-focused physical
examination—vital signs, WBC count, sedimentation rate
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Patients Receiving Antibacterial Therapy (continued)
• Nursing diagnoses– Pain (related to infection)– Infection– Hyperthermia– Risk for Injury (related to adverse drug
effects)– Deficient knowledge, related to drug therapy
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Patients Receiving Antibacterial Therapy (continued)
• Nursing diagnoses– Risk for Deficient Fluid Volume (related to
fever, diarrhea caused by adverse drug effects)
– Risk for Noncompliance (related to adverse drug effects, deficient knowledge, or cost of medication)
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Patients Receiving Antibacterial Therapyn (continued)
• Planning—patient will– Report diminished signs and symptoms of
infection, decreased fever and fatigue, increased appetite)
– Be free from, or experiences minimal adverse effects
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Patients Receiving Antibacterial Therapyn (continued)
• Planning—patient will– Verbalize an understanding of the drug’s use,
adverse effects and required precautions.– Demonstrate proper self-administration of the
medication (e.g., dose, timing, when to notify provider)
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Patients Receiving Antibacterial Therapy (continued)
• Implementation– Monitor vital signs and symptoms of infection– Monitor for hypersensitivity reaction– Monitor for severe diarrhea– Administer drug around the clock– Monitor for superinfection– Monitor intake of OTC products– Monitor for photosensitivity
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Patients Receiving Antibacterial Therapy (continued)
• Implementation– Determine food and beverage interactions– Monitor IV site for signs of tissue irritation,
severe pain, extravasation– Monitor for side effects, renal function,
symptoms of ototoxicity, compliance with antibiotic therapy
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Patients Receiving Antibacterial Therapy (continued)
• Evaluation—patient– Reports diminished signs and symptoms of
infection, decreased fever – Is free from, or experiences minimal adverse
effects.
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Patients Receiving Antibacterial Therapy (continued)
• Evaluation—patient– Verbalizes an understanding of the drug’s
use, adverse effects and required precautions.
– Demonstrates proper self-administration of the medication (e.g., dose, timing, when to notify provider).