Download Drug Therapy of Urinary Tract Infections

Drug Therapy of Urinary Tract Infections
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Most common infection
More common in females than males
In males, they are associated with complications
Limited to the urine or invade tissues of the urinary tract
Classified according to location
• Lower - cystitis
• Upper - pyloneph
Referred to as
• Uncomplicated
• Complicated – predisposing factor
Treating UTI
• Antibiotics
• Sulfonamides
• Trimethoprim
• Sulfonamides and Trimethoprim inhibit bacterial growth by preventing the synthesis of folic
acid. Folic acid is essential for the production of DNA, RNA, and proteins.
• Penicillins
• Aminoglycosides
• Cephalosporins
• Fluoroquinolones
• Urinary Antiseptics
• Nitrofurantoin
• Methenamine
• Nalidixic Acid
• Cinoxacin
Treating Acute Cystitis (lower UTI)
• Three types of oral therapy
• Single-dose therapy (least effective, but often used for uncomplicated UTI)
• Short-course therapy (uncomplicated UTI, less costly, used for pt that are noncompliant – can help
decrease bacterial resistance)
• Conventional therapy
• First-Line Drugs
• Trimethoprim/sulfamethoxazole
• Trimethoprim
• Ciprofloxacin
Treating Acute Uncomplicated Pyelonephritis (upper UTI)
• Mild to moderate infection (treated for about 14 days)
• Trimethoprim/sulfamethoxazole
• Ciprofloxacin
• Severe infection (IV antibiotic for 24-48 and then follow with oral antibiotic)
• Ciprofloxacin
• Ceftriaxone
• Ceftazidime
• Ampicillin/sulbactam
Recurrent UTI
• Relapse – recolonization of the original bacteria – shortly after finishing antibiotic – could be a structural
abnormality or chronic prostitis – treatment could last up to 4-6wks with oral agent
• 20% of recurrent UTI
• Progressive drug therapy
• Norfloxacin, trimethoprim/sulfamethoxazole
• Reinfection – colonization with new organism, commonly related to sexual intercourse or use of contraceptive
agents – urine will be collected regularly for culture
• 80% of recurrent UTI
• Involve lower urinary tract
• 3 or more infections a year should be treated prophylactically for 6 months
• Trimethoprim/sulfamethoxazole, nitrofurantoin, trimethoprim
Trimethoprim (Proloprim)
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MOA: suppresses synthesis of tetrahydrofolic acid – broad spectrum – used for acute uncomplicated UTI,
commonly combined with sulfamethoxazole**
Adverse Effects: itching, rash, GI reactions (epigastric, N/V, irritation of epiglottis, stomatitis)
Caution in folate deficiency, bone marrow suppression
Trimethoprim/Sulfamethoxazole (TMP/SMZ)
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MOA: Inhibits consecutive steps in the synthesis of tetrahydrofolic acid – together they have POWERFUL results,
(treat anything from UTI to pneumocystiscarini)
Adverse Effects:
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Rash: Stevens-Johnson syndrome (do not administer to clients with allergies to sulfa, thiazide diuretics,
sulfonylurea-type oral hypoglycemis, and loop diuretics; Stop at first indication of hypersensitivity such
as rash)
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blood dyscrasias (agranulytosis, thromocytopenia, leukopenia)(Draw baseline/periodic CBC; observe
for any bleeding episodes, sore throat or pallor; If symptoms occur notify Doc)
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renal damage
• Jaundice/ increased bilirubin lvls* (avoid giving to preggo near term or breastfeeding mother or infants
less than 2mnts; monitor liver function)
• Photosensitivity* (avoid prolonged exposure to sunlight
Maintain hydration to protect the kidneys to prevent crystaluria *(instruct client 8-10 glasses of water a day)
TMP-SMZ is the DOC for UTI’s caused by E.coli and other infections caused by Pneummocystiscarni
Drug interaction : Warfarin, Dilantin – sulfonamides can increase the effects of the medication
Fluoroquinolones
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Prototype: ciprofloxacin (Cipro) – broad spectrum bactericidal agent that have multiple applications (oral or IV
agents)
MOA: Inhibit bacterial DNA gyrase so that DNA replication cannot take place
Adverse Effects: GI reactions (N/V, diarrhea, abd pain), CNS effects (dizziness, HA, confusion et restlessness),
candida, seizure, tendon rupture
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Monitor IV site, it can cause extravagation
This med can also cause tendon rupture – avoid giving to pt under the age of 18. (tendon injury is reversible if
identified early)
This medication can increase serum warafin levels, monitor PT/INR
Urinary Tract Antiseptics
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Nitrofurantoin (Macrodantin, Macrobid) (broad spectrum – in low doses it is bacteriostatic, high doses -
bacteriocidal) – only used for UTI
• MOA: Injures bacteria by causing damage to DNA
• Adverse Effects:
• GI (N/V, anorexia) (take with milk or food – may also reduce dosage
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pulmonary (dyspnea, chest pain, cough and fever)(STOP medication)
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Hematologic (penia’s) Blood dyscrasias
• Peripheral neuropathy (tingles, numbness, muscle weakness, restless leg)
 Nitrofurantoin is contraindicated in clients with renal dysfunction and creatinine clearance less than 40mL/min
 Inform client that urine will have a brownish tint
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Methenamine (Mandelamine, Urex) – treatment for chronic UTI
MOA: Breaks down into ammonia and formaldehyde and formaldehyde denatures bacterial proteins to cause
cell death
Adverse Effects: GI distress, bladder irritation (mimic the symptoms of UTI), may also see hemuteria and
proteinuria
Contraindicated in liver dysfunction (due to ammonia break down) and renal impairment (due to crystaluria)
Available in enteric preparation to decrease GI effects of the drug
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Nalidixic Acid (NegGram) used to treat acute UTI and used prophylactically
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Cinoxacin (Cinobac) – very similar to nalidixic but fewer side effects
MOA: Inhibits replication of bacterial DNA causing DNA degradation and cell death
Adverse Effects: GI disturbances, visual disturbances, rash, photosensitivity
Drug Interaction: warfarin
MOA: Inhibits replication of bacterial DNA causing DNA degradation and cell death
Adverse Effects: GI disturbances, visual disturbances, rash, photosensitivity
Analgesic
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Pyridium (Azostandard) Used for symptomatic relief of urinary burning, itching, frequency, and urgency
Patient education:
• May discolor urine (orange) which will stain fabric – this is normal
• Discontinue drug use if skin or sclera develop a yellow color
Drugs for Erectile Dysfunction and Benign Prostatic hyperplasia
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Erectile Dysfunction (Also known as impotence)
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Persistent inability to achieve or sustain an erection suitable for satisfactory sexual performance
Commonly associated with chronic illness
Risk increases with advancing age
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Causes of Erectile Dysfunction
 Chronic illnesses (DM, CVD,PVD….)
 Lifestyle choices (smoking, obesity)
 Surgery
 Medication
 Psychological factors
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Treatment for Erectile Dysfunction
 Psychotherapy
 Vacuum Devices
 Surgery-penile implant
Drug Therapy
PDE5 Inhibitors I
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Prototype: Sildenafil (Viagra)
MOA: Causes selective inhibition of PDE5 which in turn increases and preserves cGMP levels in the penis
Adverse Effects: hypotension, priapism(notify doc if erection last more than 4hrs), headache, flushing, dyspepsia
Contraindications: nitrates, alpha blockers, inhibitors of CYP3A4 (med would not metabolize properly)
Oral doses of 25 mg, 50 mg, 100 mg
Drug Interactions
 Nitrates
 Alpha Blockers
 Inhibitors of CYP34A
PDE5 Inhibitors II
 Prototype: Vardenafil (Levitra) and Tadalafil (Cialis)
 MOA: Causes selective inhibition of PDE5 which in turn increases and preserves cGMP levels in the penis
 Adverse Effects: headache is the most common
Dosing
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Medication
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Dosage
Viagra
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25 mg
50 mg
100 mg
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Affected by
high fat meals
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Peak
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Duration
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Yes (increased
effects)
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1 hour
fasting
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4 hours
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Levitra
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2.5 mg
5 mg
10 mg
20 mg
Cialis
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5 mg
10 mg
20 mg
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Yes (increased
effects)
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1 hour
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4 hours
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No
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2 hours
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36 hours
Injectable
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Prototype: Papaverine Plus Phentolamine and alprostadil (Prostaglandin E 1) – 10min – 2-4 hrs
MOA: increase arterial inflow to the penis and decrease venous outflow to produce erection
Best for patients who is effected by neurological effects
Adverse Effects: priapism, fibrotic nodules, burning sensation
Do not use more than 3 times a week, only once in a 24hr period
Dosage: patient dependent
Benign Prostatic Hyperplasia
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Signs and Symptoms
 Hesitancy
 Urgency
 Frequency
 Dysuria
 Nocturia
 Straining
 Post-void dribbling
 Decreased force and caliber of stream
 Sensation of incomplete bladder emptying
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BPH Long-term Complications
 Obstructive nephropathy
 Bladder stones
 Recurrent urinary tract infections
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Treatment Modalities
 Surgery
 Drug Therapy
 5-alpha-reductase inhibitors
 Alpha1-adrenergic antagonists
 Combination of both
 Watchful waiting
5-Alpha-Reductase Inhibitors
Finasteride (Proscar)
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MOA: Inhibits type II 5-alpha-reductase, interfering with conversion of testosterone to 5-alphadihydrotestosterone
Adverse Effects: decreased ejaculate volume and libido, gynecomastia
Dosage: 1 mg, 5 mg
Dutasteride (Avodart)
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3 differences
 More complete reduction in circulating DHT
 Harmful to developing male fetus
 Extremely long half-life
Inhibits 5-alpha-reductase in reproductive tissues and skin and liver
Can be absorbed through the skin
Pregnancy Risk Category X
Alpha1-Adrenergic Antagonists
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Terazosin (Hytrin)
Doxazosin (Cardura)
Tamsulosin (Flomax)
Alfuzosin (Uroxatral)
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MOA: Relaxes smooth muscle in the bladder neck, prostate capsule, and prostatic urethra, to decrease dynamic
obstruction of the urethra
Adverse Effects: for terazosin and doxazosin is hypotension, fainting, dizziness, somnolence, nasal congestion;
for tamsulosin – abnormal ejaculation
Drug Interactions
 Antihypertensive
 Organic nitrates
 PDE5 inhibitors
 Strong inhibitors of CYP3A4
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Herbal Preparation
Saw palmetto
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Available as a dietary supplement
From berries of the American dwarf saw palmetto
Active ingredient not identified
Once thought to reduce PSA levels
Hematopoietic Growth Factors
 Accelerate neutrophil and platelet repopulation after chemotherapy
 Accelerate bone marrow recovery after autologous bone marrow transplant
 Stimulate erythrocyte production in chronic renal failure (due to lack of production of erythropoietin)
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Erythropoiesis
Production of erythrocytes, or RBCs
Largely regulated by cellular oxygen requirements
Stimulated by hypoxia & controlled hormonally by erythropoietin
Influenced by nutrients
Epoetin Alfa (Epogen, Procrit)
 Stimulates erythrocyte production (also mimics the bodies erythropoietin)
 Uses
 Chronic renal failure
 Anemia secondary to chemotherapy
 Anemia in HIV-infected clients
Epogen
 Administration
 Subcutaneous (stings, given in abdomen) or intravenous
 Do not shake vial
 Adverse effects
 Hypertension (directly related to the rate of hematocrit rise – if this occurs, the dosage should be
reduced)
 Cardiovascular events (greatest when hemoglobin exceed 12mg/dL – MI, stroke)
Nursing Interventions for Epogen
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Monitor for signs of anemia (pallor, fatigue, SOB, tachycardia)
Assess levels of consciousness (facial drooping, slurred speech, HA)
Monitor blood pressure before and during therapy (contraindicated in pts with uncontrolled HTN)
Monitor lab values (CBC, reticulocytes, hemoglobin)
Monitor for signs/symptoms of blood clots (swelling, pain, heat at site)
Monitor dietary intake (iron, folic acid, Vit B12 replacement may need to be given…if levels are decreased the
Epogen may not work well enough to fix anemia)
(Darbepoetin Alfa) Aranesp
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Longer half life
Administered less frequently (once weekly versus 3 times per week
Generally well tolerated
Hemoglobin levels should be monitored weekly until patient has stabilized, then monitor monthly
Adverse Effect: hypertension
Leukopoiesis
 Control of white blood cell production
Colony-stimulating factors
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Granulocyte Colony-Stimulating Factor: Filgrastim (Neupogen)
Granulocyte Colony-Stimulating Factor, Long Acting: Pegfilgrastim (Neulasta)
Granulocyte-Macrophage Colony-Stimulating Factor: Sargramostim (Leukine)
Filgrastim (Neupogen) G-CSF
 Stimulates neutrophil production – identical to human G-CSF (granulocyte-colony stimulating factor) Decreases
risk of infection
 Uses
 Chemotherapy-induced neutropenia
 Severe chronic neutropenia
 May also be used in patient with bone marrow transplant
 Do not administer within 24 hours before or after chemotherapy
 Given subQ or IV
 Adverse Effects
 Bone pain (most common- directly related to dose – Tylenol will help relieve the pain)
 Leukocytosis (monitor CBC 2xweek during treatment; decrease dose or stop treatment if WBC >50,000)
 Splenomegaly (long term)
Pegfilgrastim (Neulasta)
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G-CSF with sustained duration of action, similar to Neupogen (can increase uric acid level, alkaline
phosph)
Sargramostim (Leukine)
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Increases production of neutrophils, monocytes, macrophages, and eosinophils
Administered IV infusion
Adverse Effects: Leukocytosis and thrombocytosis, diarrhea, weakness, rash, malaise, bone pain
Used for bone marrow transplants
Nursing interventions
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Monitor vital signs, heart rate and rhythm
Monitor CBC (can cause increase in platelet count)
Assess for bone pain
Monitor for s/s of infection
 clients are more susceptible to infection until WBC response is achieved
Thrombocytopoiesis
Production of platelets controlled by hormone thrombopoietin
 Oprelvekin (Neumega, Interleukin-11)
 Used for thrombocytopenia caused by cancer chemotherapy
 Given subQ
 Adverse effect
 Fluid retention (retention of Na and H20) will see peripheral edema
 Cardiac Dysrhythmia (caution in HF due to fluid retention) – tachycardia Afib, Aflutter,
most likely related to plasma volume increase
 It can cause plasma volume to increase, which causes hgt, hct to decrease leading to
anemia – pt will start getting dyspnic
Use with caution in clients with cardiac disease
Teach client to avoid activities that could cause bleeding
Reach client to immediately report edema and difficulty breathing
Weigh daily
Report  bruising or hematuria
Contraindicated in clients allergic to yeast products
Drug Therapy for Renal Dysfunction
 Drugs Associated with Renal Toxicity
 Aminoglycosides
 Amphotericin B
 IV contrast
 Allopurinal, NSAIDs, PCNs, Sulfonamides
 Gold salts, heroin, lithium
 High dose acyclovir
 ACE-inhibitors, ARBS, excessive diuretic use can cause renal ischemia
 Special Needs for Renal Failure Clients
 Restricted fluid intake
 Decreased protein, phosphate and sodium
 K+, Mg+ and phosphorus restricted
 Hyperphosphatemia can lead to hypocalcemia
 Vitamin D and calcium supplements
 Iron supplements
Calcium Acetate (Phoslo)
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Binds to dietary phosphate in the gut to form calcium phosphate
MUST be taken with meals to bind phosphate
Adverse Effects: constipation
Food/Drug interaction
 Glucocorticoids (give meds at least 1 hr apart)
 Tetracyclines et thyroid hormones (give meds at least 1hr apart)
 Thiazide diuretics (assess for s/s of hypercalcemia ; tachycardia, elevated BP, muscle wkness,
constipation, lethargy)
 Spinach, rhubarb, bran et whole grain (will decrease calcium absorption)
 Phosphates, carbonates, sulfates et tartrates (IVCa precipitates with these compounds)
 Dig and parenteral Ca (can lead to severe bradycardia
 Do not use if patient is hypercalcemic
 Will see med is effective if phosp levels are down in blood work
Sevelamer (Renagel)
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Binds phosphate in the GI tract
Recommended for clients with  calcium and phosphate levels
Must take with food** in order to be effective
Adverse Effects: diarrhea, nausea, vomiting, dyspepsia, abdominal pain, and constipation
Calcitrol (Rocaltrol)
 Vitamin D analog
  serum calcium levels by promoting calcium absorption to manage hypocalcemia
 Indicated for treatment of hypocalcemia in renal failure
 Administer by mouth or IV
Cinacalcet (Sensipar)
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Calcimimetic
Treats hyperparathyroidism
Increases sensitivity of calcium-sparing receptors on cells of the parathyroid gland
Administer by mouth – absorption increased by food
Adverse Effects: Nausea, vomiting, diarrhea, hypocalcemia