Download 6. Kelly CP. A 76-year-old man with recurrent

COMMON ANTIBIOTICS
DANA BARTLETT, RN, BSN, MSN, MA
Dana Bartlett is a professional nurse and author.
His clinical experience includes 16 years of ICU
and ER experience and over 20 years of as a
poison control center information specialist. Dana
has published numerous CE and journal articles,
written NCLEX material, written textbook chapters,
and done editing and reviewing for publishers such
as Elsevire, Lippincott, and Thieme. He has written
widely on the subject of toxicology and was recently named a contributing editor,
toxicology section, for Critical Care Nurse journal. He is currently employed at the
Connecticut Poison Control Center and is actively involved in lecturing and mentoring
nurses, emergency medical residents and pharmacy students.
ABSTRACT
There are many antibiotics available in the United States to treat
various forms of infection. Understanding the benefits and risks of
antibiotic therapy, such as adverse effects associated with specific
antibiotics, and the safe administration and monitoring of patients
receiving antibiotics can appear daunting. However, issues of antibiotic
therapy may be approached by knowing the adverse effects common
to all antibiotics, those at risk of having adverse effects and the level
of severity of adverse effects as well as any testing required for
detection. The main classes of antibiotics and the specific antibiotics
available in the U.S., in particular, the aminoglycoside, carbapenem,
cephalosporin, glycopeptide, lincosamide, macrolide, penicillin,
quinolone, sulfonamide, tetracycline, metronidazole and nitrofurantoin
antibiotics are discussed.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, CGRN, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with
the policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's
Commission on Accreditation for registered nurses. It is the policy of
NurseCe4Less.com to ensure objectivity, transparency, and best
practice in clinical education for all continuing nursing education (CNE)
activities.
Continuing Education Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim
credit commensurate with the credit awarded for completion of this
course activity.
Pharmacology content is credited for 3 hours.
Statement of Learning Need
Properties of antibiotics influence medical guidelines for the treatment
of an infectious process and follow up care in terms of antibiotic use
and monitoring of treatment outcomes. The rise of antibiotic resistance
poses a significant health risk, which health professionals must
consider when deciding treatment in terms of antibiotic type and drug
qualities.
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Course Purpose
To provide nurses with knowledge of common antibiotics, as well as
the indications and the correct and safe administration of antibiotics.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses
and Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Dana Bartlett, RN, BSN, MSN, MA, William S. Cook, PhD,
Douglas Lawrence, MA, Susan DePasquale, CGRN, MSN, FPMHNP-BC –
all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, CGRN, MSN, FPMHNP-BC
Release Date: 12/12/2015
Termination Date: 12/12/2018
Please take time to complete a self-assessment of knowledge,
on page 4, sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge
learned will be provided at the end of the course.
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1. Antibiotic-associated diarrhea
a. can have a delayed onset and cause serious complications.
b. occurs after the first dose and is always mild and self-limiting.
c. only occurs in women >age 60.
d. typically affects hospitalized neonates.
2. Allergic reactions to antibiotics
a. always happen within one hour after a dose.
b. can be delayed in onset.
c. are always severe and life-threatening.
d. only occur in people who have a compromised immune
system.
3. True or false: Someone who is allergic to penicillin may be
allergic to cephalosporins.
a. True
b. False.
4. Patients who are receiving antibiotic therapy should be monitored
for
a. osteoporosis.
b. polycythemia.
c. diabetes mellitus.
d. nephrotoxicity.
5. Which of these antibiotics is well known for causing ototoxicity?
a. Carbapenems.
b. Metronidazole.
c. Aminoglycosides.
d. Quinilones.
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Introduction
This learning module discusses antibiotic therapy as well as specific
antibiotics. In particular, the aminoglycoside, carbapenem,
cephalosporin, glycopeptide, lincosamide, macrolide, penicillin,
quinolone, sulfonamide, and tetracycline antibiotics, and metronidazole
and nitrofurantoin are covered in the following sections. Antibiotics
that are not available in the United States will not be covered.
Specific aspects of antibiotic therapy raised in the following sections
include:
1. Mechanism of action
2. Considerations for administration
3. Adverse effects/warnings including the U.S. boxed warning,
more common, i.e., >10% reporting rate, adverse effects of
specific antibiotics, and, adverse effects or warnings that are
reported for all of the antibiotics of a particular class (frequency
of an adverse reaction not reported in commonly used drug
reference sources is not discussed)
4. Labeled uses
In addition, issues that are important for the safe administration of
antibiotics will be covered in this course: adverse effects common to
all antibiotics, allergic reactions and cross-reactivity, and antibiotic
resistance.
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Learning Break:
The term antibiotic is defined as a drug that is used to treat an infection, but it is
commonly used to refer to drugs that are used to treat bacterial infections. This is
technically incorrect but, given the widespread and commonly accepted use of the
term antibiotic in that context, its common use will be retained in this module.
Discussion of drug dosages, interactions, off-label uses, and all of the
possible adverse effects of each antibiotic and/or class of antibiotics
would not be practical here, and that information can easily be found
in drug reference books and package inserts. Information that is
particular to each of the antibiotic classes and important for safe
administration will be the primary focus. The primary source of
information is Lexi-Comp® or Lexi-Drugs® unless citations shown in
the following sections specifically indicate otherwise.
A Boxed Warning, sometimes called a black box warning, is a warning
that is required by the Food and Drug Administration (FDA) to be
included and prominently featured in the prescribing information of a
drug if there is potential for a severe adverse reaction (death,
permanent disability, a life-threatening event) in proportion to the
potential benefit of the drug, which requires cautious assessment of
the drug’s risks and benefits; or if there is a serious adverse reaction
that can be prevented or reduced in severity by appropriate use of the
drug, i.e., patient selection, careful monitoring, avoiding certain
concomitant therapy.
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Mechanism Of Antibiotic Action
Antibiotics are used to treat infections caused by susceptible bacteria
and all of the antibiotics interfere with some aspect of the biochemical
processes that are necessary for these microorganisms to survive. The
mechanisms of action of antibiotics are quite complex and are specific
to each class of antibiotic but the essential action of most antibiotics is
disruption of the bacteria cell membrane, most often by inhibiting
protein synthesis and making it impossible for the bacteria to maintain
intracellular homeostasis. Antibiotics are not effective treatment for
fungal or viral infections.
Adverse Effects
Reference books and package inserts provide extensive lists of adverse
effects associated with and/or caused by a drug, but these information
sources seldom quantify how likely it is that a specific adverse effect
will occur or which patients are at risk. Clinicians want to know what
adverse effects are of a practical concern and what to do about them,
but the drug information references do not often provide this type of
guidance. For example, package inserts for antibiotics warn that these
drugs can cause kidney and liver damage and should be used with
caution if the patient has, or is at risk for, hepatic and/or renal
impairment. The clinician wants to know how frequently and to whom
these adverse effects will occur but very often this information is not
given. A more specific example is that a commonly used drug
information source lists 37 adverse effects associated with cephalexin;
these range in severity from nausea to anaphylaxis and hemolytic
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anemia, but the incidence of any specific adverse effect is not
mentioned.
Given the number of adverse effects caused by or reported to be
associated with antibiotics, safely administering these drugs and
monitoring patients for adverse effects can appear daunting, but this
seemingly complex issue can be resolved by understanding the
following aspects of antibiotic treatment.
1. The adverse effects that are common to all antibiotics, which are
antibiotic-associated diarrhea, hepatic damage, and
nephrotoxicity.
2. The patient populations that are at risk for these adverse effects.
3. Differentiating between adverse effects that are minor and
severe and between the adverse effects that are observable and
those that require special testing for detection.
Antibiotic-Associated Diarrhea
Antibiotics can alter the characteristics of the flora of the gut, and this
can cause gastrointestinal problems. One of the most common adverse
effects of antibiotic therapy is antibiotic-associated diarrhea.1,2
Package inserts of commonly used antibiotics state that the prevalence
of antibiotic-associated diarrhea is not known, but it has been
estimated to be between 3%-29% and a recent review of randomized
controlled trials noted a prevalence of 14%.3
Children and the elderly are at greater risk for antibiotic-associated
diarrhea than are other patient populations, and recent surgery, the
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concomitant use of drugs that alter bowel motility, and the use of
multiple antibiotics also increases the risk.2 Signs and symptoms begin
from 1 to 16 days after initiation of therapy and the duration of
antibiotic-associated diarrhea has been reported to be from 2 to 49
days with a median of 4 days.2
Most cases of antibiotic-associated diarrhea will resolve without
sequelae, but package inserts and drug information resources for
antibiotics note that prolonged use can alter gut flora and cause
bacterial or fungal super-infection, resulting in serious illnesses such
as C. difficile-associated diarrhea and pseudomembranous colitis.
Clostridium-difficile is a gram-positive bacillus that produces exotoxins
and that can cause Clostridium-difficile-associated diarrhea. Antibiotic
use is the major risk factor for developing C. difficile infection.4 It is
considered to be primarily a nosocomial infection,2,5 and approximately
10%-20% of all cases of antibiotic-associated diarrhea are caused by
C. difficile.2 Almost all antibiotics can cause C. difficile-associated
diarrhea, but ampicillin, amoxicillin, the cephalosporins, clindamycin,
and the fluoroquinolones are the ones most associated with the
disease.4 This is a potentially serious adverse effect of antibiotic
therapy. Patients may have diarrhea for weeks, relapses are very
common, and major complications such as death and sepsis are
possible.5 Most cases of C. difficile diarrhea begin during antibiotic
therapy or shortly after therapy has been stopped. However, the onset
of C. difficile-associated diarrhea can be two to three months after
antibiotic therapy has finished.6
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Pseudomembranous colitis is an inflammatory bowel disease that is
usually caused by antibiotic use, most often with ampicillin, the
cephalosporins, clindamycin, and lincomycin,7 but any antibiotic can be
a causative agent. Pseudomembranous colitis complicates
approximately 10% of all cases of antibiotic-associated diarrhea,7 and
the mortality rate in patients who are elderly and/or have serious
complications such as toxic megacolon can be as high as 35%.7
Allergic Reactions
Allergic reactions to antibiotics are prominently mentioned in drug
information resources. Asking a patient if he/she has an allergy to any
antibiotics is part of taking a health history and is routinely done
before giving someone the first dose of an antibiotic. Allergic reactions
are a type of hypersensitivity reaction that are mediated through the
immune system.8 There are different ways of classifying allergic
reactions, but a common and useful way to do so is based on when the
allergic reaction appears immediate or delayed.9
Immediate allergic drug reactions may begin within minutes of drug
administration and usually occur within one hour. However, if the
patient has been given an oral antibiotic, has recently eaten, or if the
absorption of the drug is delayed the onset can begin past the one
hour mark.8,9
An immediate allergic reaction may cause mild signs and symptoms
such as pruritus and rash or more serious effects such as angioedema,
bronchospasm, hypotension, or anaphylaxis and death. Anaphylaxis is
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the most feared allergic drug reaction but fortunately it is an
uncommon occurrence. It has been estimated that there are one to
four cases of anaphylaxis caused by penicillin for every 10,000 doses
administered9 and anaphylactic reactions to cephalosporins and
carbapenems are rare.10,11
Delayed allergic drug reactions happen after antibiotic therapy has
been ongoing for days or weeks. The onset of signs and symptoms
may also occur several days after the patient has stopped taking the
antibiotic. Delayed allergic drug reactions are more common than the
immediate type.9
Table 1: Risk Factors for Penicillin and Antibiotic Allergy9,12
Age: Patients between the ages of 20-49 appear to be most at risk for
having an immediate reaction or an anaphylactic reaction to penicillin.
Allergies to other medications.
Hereditary factors: There is evidence that an allergy to penicillin can be
inherited, but first-degree relatives of someone who is allergic to penicillin
do not need to avoid taking the drug.
Occupational exposure: People who are exposed to penicillin at their
workplace can be sensitized to the drug.
Repeated exposures to penicillins.
Route of exposure: Parenteral administration is more likely to cause
anaphylaxis.
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The incidence of penicillin and antibiotic allergies is unclear. It has
been reported that between 5%-10% of the population has a penicillin
allergy and 1%-3% have a cephalosporin allergy: allergies to other
beta-lactam antibiotics are very seldom reported.9,12-15 However, skin
testing of people who are reported to have a penicillin allergy has
shown that 90%-99% do not have a penicillin allergy,9,14 and several
authors have concluded that only a small minority of patients who
have a self-reported or a documented penicillin allergy are truly
allergic to the drug.14,16 This discrepancy can be explained in part by
an imprecise definition of the term allergic reaction and also because
penicillin sensitivity is lost over time. Approximately 20% of patients
who had a confirmed penicillin allergy and had not been exposed to
penicillin after the initial identification of the allergy were still allergic
10 years later.9,14
The incidence of allergic reactions caused by antibiotics is miniscule
when compared to the number of doses administered and anaphylactic
reactions are a very unusual to rare occurrence.9,11 However, it has
been estimated that each year 500-1000 people die from anaphylaxis
caused by penicillin.9 Hypersensitivity reaction is the most common
adverse effect of the cephalosporins,17 and allergic reactions are
unpredictable.
Cross-Reactivity
Cephalosporins, penicillins, and the carbapenems are β-lactam
antibiotics. The β-lactam antibiotics share a similar structure and
patients who have hypersensitivity to one β-lactam antibiotic can be
hypersensitive to other drugs in that class or to other, similar
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antibiotics. Someone who is allergic to penicillin could also be allergic
to cephalosporins or carbapenems, or someone allergic to cephalexin
could be allergic to cefixime. This phenomenon is called crossreactivity.
Cross-reactivity is a well-known and well documented phenomenon but
the extent of cross-reactivity is not known.18 Cephalosporin-penicillin
cross-reactivity was considered to be relatively common and the crossreactivity between penicillins and cephalosporins was long thought to
be 10%.15,19 However, this figure appears to be too high,16 and Macy
(2014) writes: ”There is little, if any, clinically significant immunologic
cross-reactivity between penicillins and other beta-lactams.”20 The rate
of cross-reactivity between penicillins and cephalosporins is now
considered to be as low as 0.6%.21 It typically occurs between
penicillins and the first generation cephalosporins. Cross-reactivity
between penicillins and the 2nd, 3rd, and 4th generation cephalosporins
has been described as negligible;15,22 and the cross-reactivity between
penicillins and carbapenems is been reported to be <1%.15
Learning Break:
The cross-reactivity between the β-lactam antibiotics appears to be far
less than what it was traditionally considered to be and allergy testing and
challenge doses may establish the safety of giving a cephalosporin to
someone who has a penicillin allergy or vice versa. However, if an
antibiotic allergy is documented or if a patient reports that he/she has an
antibiotic allergy, the use of drugs from that class of antibiotics or the use
of an antibiotic with which there may be cross-reactivity is
contraindicated.
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Hepatic Damage
Prescribing information for many antibiotics often instruct clinicians to
use these drugs “… with caution in patients with preexisting liver
disease or hepatic impairment … Discontinue immediately if
symptoms of hepatitis occur (malaise, nausea, vomiting, abdominal
colic, fever). Serious liver injury, including irreversible drug induced
hepatitis and fulminant hepatic failure (sometimes fatal) have been
reported with use.”31-34
Antibiotics are the most common cause of drug-induced liver
damage,35,36 and amoxicillin-clavulanate is the most common drug
involved in drug-induced liver injury.37-39 (Note: this does not include
deliberate overdose of acetaminophen). Approximately 23% of
individuals on amoxicillin/clavulanate experience non-significant
increases in hepatic enzymes, and the incidence of hepatotoxicity
caused by amoxicillin has been estimated to be 1.7 cases per 10,000
prescriptions.39 Azithromycin, ciprofloxacin, clarithromycin,
erythromycin, minocycline, nitrofurantoin, oxacillin, quinolones,
sulfamethoxazole-trimethoprim, and telithromycin can cause liver
damage, as well.36,40-43
Risk factors for drug-induced liver damage are not clearly understood
and have not been definitively identified. In the majority of cases the
damage is temporary and once the offending drug has been
discontinued, the liver repairs itself.38
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Learning Break:
Antibiotics may not be directly injurious to the liver but the metabolism
and clearance of antibiotics may be affected by hepatic impairment,
causing drug levels to become elevated and increasing the risk for
adverse effects of the drug.
Nephrotoxicity
Drug information resources and prescribing information for almost all
of the antibiotics discussed in this learning module state the drugs
should be used with caution in patients with renal impairment,
antibiotics may cause renal impairment, or that the dosage of the
antibiotic should be adjusted according to the patient’s level of kidney
function. Some of the cephalosporins, the carbapenems, and the
glycopeptides have been implicated as nephrotoxic.44-47
Vancomycin is particularly injurious to the kidneys and Elyasi, et al.,
(2012) noted that renal toxicity was reported in 10%-20% and 30%40%, respectively, of patients who received conventional or high dose
treatment with vancomycin.45
Antibiotic Resistance
Antibiotic resistance occurs when a microorganism survives and
multiplies while in the presence of an antibiotic that would usually kill
that specific microorganism. Antibiotic resistance is considered to be a
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significant public health problem.23 Microorganisms that are resistant
to the available antibiotics have become more common and infections
caused by these resistant strains can be quite difficult to treat and
have serious implications for the patient and the health care
system.24,25
Antibiotic resistance is a long-standing problem. The first penicillin
resistant strains of bacteria were noted four years after the drug was
mass produced and methicillin-resistant Staphylococcus aureus was
detected within a year of the first clinical use of the drug.26 Antibiotic
resistance is a complex phenomenon and there are many contributing
factors.
Table 2: Mechanisms of Antibiotic Resistance
23-25,27
Bacterial mutations
Inadequate diagnostic capability
Inadequate infection control
Lack of new antibiotics
Non-prescription availability of antibiotics
Patient compliance
Public hygiene practices
Prescribing practices
Transmission of resistance
Antibiotic resistance is of particular importance in regard to methicillinresistant Staphylococcus aureus, often referred to as MRSA, and
tuberculosis. Staphyloccocus aureus is a very common microorganism
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that is the cause of many respiratory and skin infections. Methicillinresistant S. aureus are microorganisms that are resistant to penicillins
and other β-lactam antibiotics. Infections with MRSA are a significant
public health problem, causing approximately 100,000 new infections
and 19,000 deaths per year.28 (Note: The term MRSA is used but
methicillin is no longer produced).
Tuberculosis (TB) is still a major health problem in many parts of the
world, but fortunately the disease is curable. However, drug-resistant
TB, multi-drug resistant TB, and extensively-drug resistant TB are
strains of TB that cannot be cured by treatment with the first-line antituberculars or many of the other anti-microbials.29 In fact, the World
Health Organization (WHO) estimated that during 2014, 3.3% all new
cases of tuberculosis and approximately 20% of all cases of
tuberculosis in patients who had been previously treated were caused
by a multi-drug resistant strain of tuberculosis mycobacterium.30
Aminoglycosides
The aminoglycosides include amikacin, gentamicin, streptomycin, and
tobramycin. These drugs are available as intramuscular (IM) and
intravenous (IV) solutions, ophthalmic ointments and solutions, oral
tablets and solutions, oral inhalation solutions, otic solutions, and
topical creams and ointments. Neomycin is not available in the IM or
IV form.
Mechanism of Action
The aminoglycosides inhibit bacterial protein synthesis.
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Administration
The patient should be monitored for nephrotoxicity, neurotoxicity, and
ototoxicity. Peak and trough levels should be periodically measured,
particularly in critically ill patients and patients who are susceptible to
the nephrotoxic and ototoxic effect of aminoglycosides. The need for
and the timing and frequency of peak and trough drug levels are
determined on a case-by-case basis and by the policy of the treating
facility. Blood urea nitrogen and serum creatinine should be measured,
intake and output recorded, and audiometric testing should be done
before, during, and after therapy with an aminoglycoside. Crossreactivity between the aminoglycosides may exist.
Adverse Reactions/Warnings
The aminoglycosides are well known for causing nephrotoxicity,
ototoxicity, and neuromuscular blockade and paralysis after
concomitant use of anesthesia or muscle relaxants, and there are U.S.
Boxed Warnings regarding these adverse effects. Neomycin may cause
neurotoxic effects such as muscle twitching, numbness, and seizures,
especially in patients who have renal impairment or are taking
nephrotoxic or ototoxic drugs.
Diarrhea, irritation of the mouth or rectal area, nausea, and vomiting
have been reported to occur in 1%-10% of patients taking neomycin.
Streptomycin has been associated with arachnoiditis, optic nerve
dysfunction, peripheral neuritis, and encephalopathy.
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Nephrotoxicity
Nephrotoxicity is a well-known adverse effect of the aminoglycosides,
affecting 5%-25% of patients treated with these drugs.48 Risk factors
for aminoglycoside nephrotoxicity include advanced age, dehydration,
hepatic dysfunction, hypothyroidism, increasing duration of therapy,
metabolic acidosis, pregnancy, renal impairment, and sodium
depletion.49
The mode of therapy also influences the risk of nephrotoxicity and
current recommendations are to use once daily dosing, also called
extended interval therapy; this method has been reported to decrease
the incidence of aminoglycoside nephrotoxicity from 17% to 0-5%.49
Ototoxicity
Aminoglycosides can cause damage to the balance and hearing
structures of the inner ear. These effects have been reported to occur
in approximately 10% of all patients who have been given an IV
aminoglycoside and the effects on hearing can be permanent.48,50
Ototoxicity can also occur from the use of aminoglycoside ear
drops.51,52 All of the aminoglycosides can affect hearing and balance,
but gentamicin and streptomycin are more likely to cause vestibular
damage. Amikacin and neomycin predominantly affect hearing and
tobramycin affects balance and hearing equally.53,54
Patients who have renal impairment, high drug levels, or are receiving
other ototoxic or nephrotoxic drugs are at high risk for aminoglycoside
ototoxicity, but balance and hearing disorders can happen to patients
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who have normal renal function and therapeutic drug levels.53 There is
evidence that suggests a genetic susceptibility exists for
aminoglycoside-induced hearing loss.54,55 Because of the risk of
ototoxicity it is recommended that the course of therapy with an
aminoglycoside be as short as possible,48,50 and that audiometric
testing be done before, during, and after therapy. Hearing loss after
aminoglycoside therapy has been stopped has been reported.48,50,55-57
Labeled Uses
Amikacin
Amikacin is used as a treatment of serious infections caused by
organisms such as Pseudomonas, Proteus, Serratia, and other gramnegative bacilli that are resistant to gentamicin and tobramycin.
Examples of these infections include bone infections, endocarditis,
septicemia, and respiratory infections.
Gentamicin
Abdominal infections, bone infections, endocarditis, respiratory
infections, septicemia, skin and soft tissue infections, and urinary tract
infections caused by Pseudomonas, Proteus, Serratia, and grampositive Staphylococcus.
Neomycin
Neomycin is used as an adjunctive therapy for the treatment of
hepatic coma and as a surgical prophylaxis.
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Streptomycin
Streptomycin is used for the treatment of patients that have
tuberculosis, used in conjunction with other anti-tubercular drugs
when the primary medications ethambutol, isoniazid, pyrazinamide,
and rifampin cannot be used. Streptomycin is also used to treat
infections that cannot be treated with less toxic drugs, infections
caused by Brucella, E. faecalis, Enterobacter aerogenes, Enterococcus
faecalis in urinary tract infections, Escherichia coli, Francisella
tularensis, Haemophilus ducreyi, Klebsiella granulomatis, Klebsiella
pneumoniae pneumonia, Proteus spp, and Yersinia pestis.
Chancroid, plague, and gram-negative bacteremia can be treated with
streptomycin.
Tobramycin
Tobramycin is used for the treatment of documented or suspected
infections caused by susceptible gram-negative bacilli, including
Pseudomonas aeruginosa.
Carbapenems
The carbapenems are β-lactam antibiotics. These drugs, along with the
cephalosporins and the penicillins, are called β-lactams because they
all have a structure called the β-lactam ring as part of their core.
Imipenem is combined with cilastatin. Cilastatin prevents renal
metabolism of imipenem. The carbapenems are available as IV
solutions.
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Table 3: Carbapenem Antibiotics
Doripenem
Ertapenem
Imipenem/Cilastatin
Meropenem
Mechanism of Action
The carbapemens inhibit bacterial cell wall synthesis.
Administration
Cross-reactivity with cephalosporins and allergic hypersensitivity is
possible, and the use of carbapenems for patients who have had
anaphylactic or hypersensitivity reactions to other β-lactam antibiotics
is contraindicated. Concomitant use of valproic acid and a carbapenem
can lower the blood concentration of valproic acid and cause seizures;
this combination should be avoided.58
Adverse Effects/Warnings
The carbapenems have been associated with an increased risk for
seizures and thrombocytopenia when they are used for elderly patients
and/or patients who have a brain lesion, epilepsy, or impaired renal
function.59 The strength of this association is not clearly defined,60 but
dose adjustments based on body weight and creatinine clearance are
advised when using a carbapenem for these patient populations.
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Diarrhea and headache are common side effects of doripenem.
Prolonged use of carbapemens can cause alteration of the gut
microflora and C. difficile-associated diarrhea and pseudomembranous
colitis. Decreased hematocrit (18%) and hemoglobin (15%),
eosinophilia and thrombocytopenia (13%), and increased serum AST
(18%) have been reported in infants and children receiving
imipenem.61
The use of a carbapenem is contraindicated if the patient has a history
of hypersensitivity to carbapenems or if he/she has had an
anaphylactic reaction to a β-lactam antibiotic.
Labeled Uses
Doripenem
Doripenem is prescribed to treat patients who have complicated intraabdominal infections and complicated urinary tract infections caused
by susceptible aerobic gram-positive and gram-negative bacteria and
anaerobic bacteria
Ertapenem
Ertapenem is prescribed to treat patients who have acute pelvic
infections including postpartum endomyometritis, septic abortion and
post-surgical gynecologic infections, community-acquired pneumonia,
and complicated intra-abdominal, skin and skin structure infections,
and urinary tract infections. It is also prescribed as a prophylactic drug
for prevention of surgical site infections after elective colorectal
surgery.
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Imipenem/Cilastatin
Iminpenen/Cilastatin is prescribed to treat patients who have bacterial
septicemia, bone, joint, skin or skin structure infections, intraabdominal infections, endocarditis caused by Staphylococcus aureus,
gynecologic infections, and lower respiratory tract infections.
Meropenem
Meropenem is prescribed to treat bacterial meningitis in pediatric
patients 3 months and older if the causative microorganism is
Streptococcus pneumoniae, Haemophilus influenzae, or Neisseria
meningitides. It is also used to treat complicated skin or skin structure
infection and intra-abdominal infections.
Cephalosporins
The cephalosporins are classified as first-generation, secondgeneration, third-generation, fourth-generation, or fifth-generation.
The classification system is based on the effectiveness of each
generation against specific microorganisms and the chronological order
in which they were developed. For example, the first generation
cephalosporins are used for infections caused by certain strains of
Streptococci and Staphylococcus aureus and the second-generation
cephalosporins are effective against a broader spectrum of bacteria.
Cephalosporins are available as IV solutions and oral capsules, tablets
and suspensions.
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Learning Break:
Bacteria contain a compound called beta-lactamase that destabilizes the
β-lactam ring of β-lactam antibiotics and makes them less effective.
Clavulanic acid is a drug that inhibits the activity of beta-lactamase.
These and other beta-lactamase inhibitors are added to antibiotics to
increase their effectiveness.
Table 4: Cephalosporins
First-generation: Cefadroxil, cefazolin, and cephalexin
Second-generation: Cefaclor, cefotetan, cefoxitin, cefprozil, and
cefuroxime
Third-generation: Cefdinir, cefditoren, cefixime, cefotaxime,
cefpodoxime, ceftazidime, ceftibuten, and ceftriaxone
Fourth generation: Cefepime
Fifth generation: Ceftaroline fosamil, ceftolozane and tazobactam
(A cephalosporin combination)
Mechanism of Action
The mechanism of action is the inhibition of the synthesis of a specific
part of the bacterial cell wall.
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Administration
Patients should be observed closely for signs and symptoms of
hypersensitivity reaction, especially after the first dose. Many drug
reference sources advise that renal function should be monitored
during therapy with a cephalosporin, and dosing adjustments based on
creatinine clearance are recommended for essentially all of the
cephalosporins.
Renal injury or impairment is an unusual and rarely reported
complication of these medications. However, if the patient has
decreased renal function, if he/she is concomitantly receiving a
nephrotoxic drug, or if the patient has risk factors for renal impairment
or injury such as advanced age or dehydration, then monitoring renal
function during therapy with a cephalosporin would be prudent and is
recommended.
Cefazolin, cefotetan, ceftriaxone, and ceftolozane/tazobactam contain
sodium and this should be considered if the patient has sodium
intolerance or congestive heart failure. If the patient has a
hypersensitivity to a cephalosporin, administration of any other
cephalosporin is contraindicated and caution should be used when
administering another β-lactam antibiotic.
Adverse Effects/Warnings
Hypersensitivity reactions, immediate and delayed, are the most
common adverse effects of the cephalosporins. Diarrhea, nausea, and
vomiting are common, self-limiting side effects of the oral
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cephalosporins. Prolonged use of cephalosporins can cause alteration
of the gut microflora and C. difficile-associated diarrhea and
pseudomembranous colitis. Many of the cephalosporins cause an
increase in the INR laboratory test used to monitor individuals being
prescribed warfarin.
Cefotetan and ceftaroline fosamil can cause a positive direct Coombs
test. Hemolytic anemia has been reported after administration of
cefotetan but not ceftaroline fosamil. If anemia develops during
therapy with cefotetan or cetaroline fosamil, drug-induced hemolytic
anemia should be part of the differential diagnosis list. Cefpodoxime
has been noted to cause diaper rash.
Labeled Uses
There are currently 19 cephalosporins available in the U.S., and a
complete discussion of their antimicrobial actions and labeled uses is
beyond the scope of this learning module, but the labeled uses are
summarized below.
Cefadroxil
Pharyngitis and/or tonsillitis, skin and skin structure infections, and
urinary tract infection.
Cefazolin
Biliary tract infections, bone and joint infections, endocarditis, genital
infections, perioperative prophylaxis, respiratory tract infections,
septicemia, skin and skin structure infections, and urinary tract
infections.
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Cephalexin
Bone infections, genitourinary infections, otitis media, respiratory tract
infections, skin and skin structure infections, and prophylaxis for acute
infective endocarditis.
Cefaclor
Acute bacterial exacerbations of chronic bronchitis (extended-release
tablets only), lower respiratory tract infections (capsules and oral
suspension only), otitis media (capsules and oral suspension only),
pharyngitis/tonsillitis, secondary bacterial infections of acute bronchitis
(extended-release tablets only), and uncomplicated skin and skin
structure infections.
Cefotetan
Perioperative prophylaxis, intra-abdominal infections and other mixed
infections, respiratory tract, skin and skin structure, bone and joint,
urinary tract, and gynecologic infections, and septicemia.
Cefoxitin
Bone and joint infections, gynecological infections, intra-abdominal
infections, lower respiratory tract infections, perioperative prophylaxis,
septicemia, skin and skin structure infections, and urinary tract
infections.
Cefprozil
Pharyngitis or tonsillitis, otitis media, secondary bacterial infection of
acute bronchitis and acute bacterial exacerbation of chronic bronchitis,
and uncomplicated skin and skin structure infections.
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Cefuroxime
Acute bacterial maxillary sinusitis (tablets and oral suspension only),
acute otitis media (tablets and oral suspension only), bone and joint
infections (injection only), acute bacterial and secondary bacterial
bronchitis (tablets only), impetigo, lower respiratory tract infections
(injection only), early Lyme disease (tablets only),
pharyngitis/tonsillitis (tablets and oral suspension only), septicemia
(injection only), uncomplicated skin and skin structure (tablets only),
surgical (perioperative) prophylaxis (injection only), and urinary tract
infections (tablets and injection only).
Cefdinir
Acute bacterial otitis media, acute exacerbations of chronic bronchitis,
acute maxillary sinusitis, community-acquired pneumonia,
pharyngitis/tonsillitis, and uncomplicated skin and skin structure
infections.
Cefditoren
Acute bacterial exacerbation of chronic bronchitis or communityacquired pneumonia, pharyngitis/tonsillitis, and uncomplicated skin
and skin structure infections.
Cefixime
Acute exacerbations of chronic bronchitis, otitis media,
pharyngitis/tonsillitis, uncomplicated urinary tract infections, and
uncomplicated cervical or urethral gonorrhea.
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Cefotaxime
Bacteremia or septicemia, bone or joint infections, CNS infections,
genitourinary infections, gynecologic infections, intra-abdominal
infections, lower respiratory tract infections, skin and skin structure
infections, and surgical prophylaxis.
Cefpodoxime
Chronic bronchitis, acute bacterial exacerbation, gonorrhea, otitis
media, acute pharyngitis/tonsillitis, community-acquired pneumonia,
sinusitis-acute maxillary, uncomplicated skin and skin structure
infections, and uncomplicated urinary tract infections.
Ceftazidime
Bacterial septicemia, bone and joint infections, CNS infections, empiric
therapy in the immunocompromised patient, gynecologic infections,
intra-abdominal infections, lower respiratory tract infections, skin and
skin structure infections, and urinary tract infections.
Ceftibuten
Acute exacerbations of chronic bronchitis, acute bacterial otitis media,
and pharyngitis/tonsillitis.
Ceftriaxone
Acute bacterial otitis media, bacterial septicemia, bone and joint
infections, intra-abdominal infections, lower respiratory tract
infections, meningitis, pelvic inflammatory disease, skin and skin
structure infections, uncomplicated gonorrhea, urinary tract infections,
and surgical prophylaxis.
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Cefepime
Febrile neutropenia, intra-abdominal infections, moderate to severe
pneumonia, skin and skin structure infections, and urinary tract
infections, including pyelonephritis.
Ceftaroline fosamil
Acute bacterial skin infections and community-acquired bacterial
pneumonia.
Ceftolozane and Tazobactam
Intra-abdominal infections and urinary tract infections.
Glycopeptides
The glycopeptide antibiotics include dalbavancin, oritavancin,
telavancin, and vancomycin. These drugs are available as oral capsules
and solutions and IV solutions.
Mechanism of Action
Inhibition of bacterial cell wall synthesis.
Administration
The IV glycopeptides must be administered slowly (30-60 minutes,
depending on the drug) and other medications should not be given
concurrently through the same IV line. Oritvancin will cause a false
elevation of the aPTT (activated partial thromboplastin time) for 48
hours after a dose, and the co-administration of oritavancin and
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warfarin may increase the risk of bleeding. Extravasation of
vancomycin can cause tissue irritation and necrosis.
Adverse Effects/Warnings
Rapid IV administration of a glycopeptides antibiotic can cause
irritation at the injection site, erythema, pruritus, and urticaria, a
phenomenon called the “red man syndrome.”62,63 Dalbavancin has
been reported to cause reversible elevations of ALT up to 3 times the
upper limit of normal; this laboratory abnormality is reversed once
therapy with the drug has been stopped.62 Osteomyelitis was reported
to occur during the clinical trials of oritavancin,64 and although the
number of patients affected was very small it is recommended that
patients be monitored for signs and symptoms of osteomyelitis.65
Prolongation of the QT interval of the heart has been mentioned as an
adverse effect of therapy with telavancin.66,67 The significance of this
effect is not known but if possible, telavancin should not be given to
patients who have heart conditions such as congenital long QT
syndrome, prolonged QT interval, left ventricular hypertrophy,
uncompensated heart failure, or who are receiving other drugs that
can prolong the QT interval.68 As with many other antibiotics, the
glycopeptides (vancomycin in particular) can cause nephrotoxicity,44,69
especially in at-risk patient populations. Vancomycin can cause
necrosis if there is an extravasation.70
Dosing of these drugs must be adjusted based on creatinine clearance.
Periodic measurement of renal function should be done during therapy
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with the glycopeptides and trough levels of vancomycin should be
measured in patients deemed to be at risk for kidney damage.
Prolonged use of glycopeptides can cause alteration of the gut
microflora and C. difficile-associated diarrhea and pseudomembranous
colitis.
Labeled Uses
Dalbavancin
Treatment of adults who have acute bacterial skin and/or skin
structure infections caused by of these gram-positive microorganisms:
Staphylococcus aureus (including methicillin-susceptible and
methicillin-resistant strains), Streptococcus pyogenes, Streptococcus
agalactiae, and the Streptococcus anginosus group.
Oritavancin
Treatment of adults who have an acute bacterial skin and/or skin
structure infection caused by one of these gram-positive organisms:
Staphylococcus aureus (including methicillin-susceptible and
methicillin-resistant isolates), Streptococcus pyogenes, Streptococcus
agalactiae, Streptococcus dysgalactiae, Streptococcus anginosus
group, and Enterococcus faecalis (vancomycin-susceptible isolates
only).
Telavancin
Treatment of complicated skin and/or skin structure infections caused
by methicillin-susceptible or methicillin-resistant Staphylococcus
aureus, vancomycin-susceptible Enterococcus faecalis, and
Streptococcus pyogenes, Streptococcus agalactiae, or Streptococcus
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anginosus group. Treatment of hospital-acquired and ventilatoracquired bacterial pneumonia.
Vancomycin
Vancomycin IV is used to treat patients who have Staphylococcal or
Streptococcal infections. Oral vancomycin is used to treat C. difficileassociated diarrhea and enterocolitis caused by Staphylococcus aureus
(including methicillin-resistant strains).
Macrolides
The macrolide antibiotics include azithromycin, clarithromycin,
erythromycin, fidaxomicin, and telithromycin. The macrolide antibiotics
are available as IV solutions, ophthalmic preparations, oral capsules,
suspensions, and tablets, and topical preparations
Mechanism of Action
The macrolide antibiotics inhibit bacterial protein synthesis.
Administration
Intravenous azithromycin should be administered slowly over 1 hour.
Oral azithromycin extended release should be taken on an empty
stomach, 1 hour before or 2 hours after a meal.
Clarithromycin should be dosed every 12 hours to avoid peak and
trough levels. Do not give erythromycin with acidic beverages or milk.
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Adverse Effects/Warnings
The macrolide antibiotics can lengthen the QT interval of the heart and
cause torsades de pointes.71 The clinical significance of this effect has
not been clearly defined,72 and there is evidence that torsades de
pointes caused by a macrolide is rare and only occurs if the patient has
specific risk factors including but not limited to, advanced age,
bradycardia, congestive heart failure, electrolyte abnormalities, female
gender, and left ventricular hypertrophy.72 Nonetheless, drug
information sources caution that there is substantial evidence that
indicates: 1) these drugs can prolong the QT interval and cause
torsade de pointes;71 2) clinicians should consider avoiding the use of
these drugs in patients who have the aforementioned (and other) risk
factors;71 and, 3) prescribers “… should consider the risk of QT
prolongation which can be fatal when weighing the risks and benefits
of azithromycin for at-risk groups.”73
The macrolide antibiotics have been associated with exacerbating or
inducing myasthenia gravis or myasthenic crisis.74,75 Prolonged use of
macrolides can cause alteration of the gut microflora and C. difficileassociated diarrhea and pseudomembranous colitis.
Labeled Uses
Azithromycin
Azithromycin is prescribed for treatment of patients who have acute
bacterial exacerbations of chronic obstructive pulmonary disease,
acute bacterial sinusitis, community-acquired pneumonia, genital ulcer
disease in men, otitis media, Mycobacterium avium complex, pelvic
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inflammatory disease, pharyngitis or tonsillitis, skin and/or skin
structure infections, and uretheritis and cervicitis. It is also prescribed
for prevention of Mycobacterium avium complex in patients who have
advanced human immunodeficiency virus (HIV) infection.
Clarithromycin
Infants and children 6 months and older:
Acute maxillary sinusitis, acute otitis media, community-acquired
pneumonia, disseminated mycobacterial infections, pharyngitis or
tonsillitis, and uncomplicated skin/skin structure infections.
Clarithromycin can also be prescribed for prevention of disseminated
mycobacterial infections caused by Myobacterium avium complex
disease in patients who have an advanced HIV infection and are 20
months or older.
Adults:
Acute exacerbation of chronic bronchitis, acute maxillary sinusitis,
community-acquired pneumonia, duodenal ulcer disease due to H.
pylori (used along with other medications), disseminated
mycobacterial infections due to Myobacterium avium or Myobacterium
intracellulare, pharyngitis or tonsillitis, and uncomplicated skin/skin
structure infections. Clarithromycin can also be prescribed for
prevention of disseminated mycobacterial infections caused by
Myobacterium avium complex disease in patients who have an
advanced HIV infection.
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Erythromycin
Erythromycin is used for treatment of susceptible bacterial infections
and can be used alone or with neomycin for pre-surgical bowel
decontamination.
Fidaxomicin
Treatment of Clostridium difficile-associated diarrhea.
Telithromycin
Treatment of patients 18 years and older who have mild to moderate
cases of community-acquired pneumonia.
Lincosamides
The lincosamide antibiotics include clindamycin and lincomycin. The
lincosamides are available as solutions for IM and IV use and topical
preparations - creams, foams, gels, lotions, solutions, suppositories,
and swabs.
Mechanism of Action
Inhibition of bacterial protein synthesis.
Adverse Effects/Warnings
Clindamycin systemic and lincomycin: U.S. Boxed Warning –
C. difficile-associated diarrhea has been reported and may be mild to
severe and possibly fatal; it can cause severe and possibly fatal colitis.
It should be reserved for serious infections where less toxic
antimicrobial agents are inappropriate, and should not be used in
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patients with nonbacterial infections such as most upper respiratory
tract infections.
These drugs should be used with caution in patients who have severe
liver disease or renal impairment.
Clindamycin topical - Greater than 10% dermatologic effects such as
erythema, exfoliation, irritation, pruritus, and xeroderma; greater than
10% genitourinary effects such as vaginal moniliasis and vulvovaginal
pruritus.
Labeled Uses
Clindamycin
Bone and joint infections, gynecological infections, intra-abdominal
infections, lower respiratory tract infections, septicemia caused by S.
aureus, serious infections caused by susceptible strains of streptococci,
pneumococci, and staphylococci, and skin and skin structure
infections.
Clindamycin Topical
Treatment of bacterial vaginosis and severe acne.
Lincomycin
Treatment of serious infections caused by susceptible strains of
streptococci, pneumococci, and staphylococci. Lincomycin should only
be used for penicillin-allergic patients or other patients for whom
penicillin is inappropriate.
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Penicillins
The penicillins are perhaps the best known of the antibiotics although
they are the second systemic antibiotics to be developed. Penicillin was
first used clinically in 1941 and even though the patient did not
survive, penicillin was recognized as a major advance in antimicrobial
therapy; the drug was effective even when extensively diluted, it was
freely diffusible, and it was minimally toxic.76
The penicillins are available as oral tablets, chewable and extended
release tablets, oral suspensions, and IM and IV solutions. Of the
penicillins, it should be noted that sulbactam and tazobactam are betalactamase inhibitors. Additionally, procaine (a local anesthetic) is used
with penicillin G procaine to decrease the pain of IM injection of the
drug. The penicillins are listed in the table below.
Table 5: Penicillins
Amoxicillin and Clavulanate
Ampicillin
Ampicillin and Sulbactam
Cloxacillin
Dicloxacillin
Nafcillin
Oxacillin
Penicillin G benzathine
Penicillin G (Parenteral/Aqueous)
Penicillin G procaine
Penicillin V potassium
Piperacillin
Piperacillin and tazobactam
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Mechanism of Action
The penicillins inhibit bacterial cell wall synthesis by binding to
penicillin-binding proteins on susceptible bacteria.
Administration
Intravenous infusions of penicillins should be administered slowly;
rapid infusion has been associated with seizures. Injection of penicillin
G benzathine, penicillin g parenteral/aqueous, and penicillin g procaine
intra-arterially, penicillin g procaine IV, or any of these drugs given
near a major peripheral nerve can cause severe, permanent
neurovascular damage.
Injection of penicillin G benzathine, penicillin g parenteral/aqueous,
and penicillin g procaine IM in children <2 years should not be injected
in the gluteal area; the mid-lateral muscle of the thigh should be used.
Most of the oral penicillins should be taken on an empty stomach, i.e.,
one hour before a meal or two hours after a meal. Each drug should be
checked for specific recommendations.
Adverse Effects/Warnings
All of the penicillins should be used with caution if the patient has renal
impairment and as with other antibiotics, prolonged use of penicillin
antibiotics can cause C. difficile-associated diarrhea and
pseudomembranous colitis. The incidence of gastrointestinal side
effects is >10% in patients receiving penicillin V potassium.
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Adverse Effects/Warnings for Specific Penicillins
Renal impairment:
Renal function should be measured before and during therapy with
amoxicillin-clavulanate, ampicillin, nafcillin, penicillin G parenteral or
aqueous, and piperacillin and dosing adjustments made based on
creatinine clearance.
Extravasation:
Nafcillin is a vessicant, a drug or substance that can cause blistering,
and extravasation of nafcillin can cause tissue necrosis.70,77
Liver Damage:
The risk of liver damage from amoxicillin-clavulanate has been
discussed and amoxicillin-clavulanate is contraindicated if the patient
previously had liver damage caused by the drug. Oxacillin has been
associated with acute hepatitis and transaminase elevations.78-80
Risk of Seizures:
Cloxacillin, penicillin G benzathine, penicillin G parenteral/aqueous,
penicillin G procaine, and piperacillin should be used with caution in
patients who have a pre-existing seizure disorder and renal
impairment as high serum levels of these drugs can increase the risk
for seizures.81
The penicllins may also increase the risk of seizures in patients who
have a brain lesion or epilepsy.
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Skin Rash:
Patients who have cystic fibrosis and receive piperacillin and patients
who have mononucleosis and receive ampicillin or piperacillin are likely
to develop a skin rash.82-84.
Sodium Content:
Nafcillin, oxacillin, penicillin G parenteral or aqueous, and piperacillin
have a sodium content that should be considered when these drugs
are prescribed for patients who need to restrict their sodium intake.
Thrombocytopenia, anemia, leucopenia, and neutropenia:
Hematologic effects have been reported after administration of
piperacillin-tazobactam.85-87
Warfarin Drug Interaction:
Dicloxacillin and nafcillin may decrease the anti-coagulant effect of
warfarin.88,89
Labeled Uses
Amoxicillin-clavulanate
Community-acquired pneumonia, otitis media, acute, respiratory tract
infections, sinusitis, skin and skin structure infections, and urinary
tract infections.
Ampicillin
Oral: Genitourinary tract infections, gastrointestinal tract infections,
and respiratory tract infections.
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Intravenous: Bacterial meningitis, gastrointestinal infections,
respiratory tract infections, septicemia and endocarditis, skin and skin
structure infections, and urinary tract infections.
Ampicillin-sulbactam
Intra-abdominal infections, gynecological infections, and skin and skin
structure infections.
Cloxacillin
Bone and joint infections, endocarditis, pneumonia, skin and skin
structure infections, and sepsis.
Dicloxacillin
Osteomyelitis, pneumonia, and skin and soft tissue infections.
Nafcillin
Bacteremia, CNS infections caused by susceptible Staphylococcus
species, endocarditis, osteomyelitis, and septicemia.
Oxacillin
Infections caused by susceptible penicillinase-producing staphylococci.
Penicillin G benzathine
Acute glomerulonephritis, respiratory tract infections, prophylaxis for
rheumatic fever and chorea, rheumatic heart disease, and syphilis and
other venereal diseases.
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Penicillin g parenteral/aqueous
Anthrax, botulism, endocarditis, gas gangrene, meningitis, pericarditis,
pneumonia, and sepsis.
Penicillin g procaine
Anthrax prophylaxis and treatment, diphtheria, endocarditis
(subacute), erysipeloid, fusospirochetosis, pneumococcal respiratory
infection, rat bite fever, skin and soft tissue infections, streptococcal
infections, syphilis, yaws, bejel, and pinta.
Piperacillin
Bone and joint infections, intra-abdominal infections, gynecological
infections, lower respiratory tract infections, skin and soft tissue
infections, urinary tract infections, and infections caused by susceptible
streptococci.
Piperacillin-tazobactam
Bacterial infections (moderate to severe), community-acquired
pneumonia, intra-abdominal infections, nosocomial pneumonia, postpartum endometriosis or pelvic inflammatory disease caused by betalactamase-producing strains of E. coli, and skin and skin structure
infections.
Sulfonamides
The sulfonamides were introduced in 1936 and they were the first
systemic antibiotics. The sulfonamides include sulfadiazine,
sulfamethoxazole-trimethoprin, sulfur and sulfacetamide, and
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sulfacetamide topical. These drugs are available as ophthalmic
preparations, oral suspensions and tablets, topical cleansers, creams,
foams, gels, lotions, pads, suspensions, and washes (sulfur and
sulfacetamide), and as IV solutions.
Mechanism of Action
The sulfonamides inhibit folic acid synthesis and this inhibits bacterial
growth. Sulfur and the sulfur in sulfacetamide is a keratolytic, a drug
that softens and removes the outer layer of the epidermis.
Administration
The oral sulfonamides should be taken with 8 ounces of water and it is
recommended that they be administered around the clock to minimize
the variations in peak and trough levels. Sulfur and sulfacetamide has
not been proven to be effective and/or safe in children <12 years.
Sulfur and sulfacetamide is contraindicated if the patient has renal
impairment, and dosages of sulfamethoxazole-trimethoprin need to be
adjusted to the creatinine clearance level.
Sulfadiazine is contraindicated in infants <2 months unless the baby is
being treated for congenital toxoplasmosis.
Sulfacetamide topical can be systemically absorbed if it is applied to
abraded, burned, or infected skin.
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Adverse Effects/Warnings
There is “… a clear association between sulfonamides and severe
dermatologic reactions.”90 These reactions, specifically StevensJohnson syndrome (SJS) and toxic epidermal necrolysis (TEN), are
very uncommon40 but the sulfonamides such as sulfamethoxazoletrimethoprin are among the most common causes of SJS and TEN and
these dermatologic adverse effects can cause serious morbidity and
death.91-93 Hepatotoxicity is not a common adverse effect of the
sulfonamides, but sulfamethoxazole-trimethoprim is one of the top
three causes of drug-induced liver injury.36
Stevens-Johnson syndrome and TEN may accompany hepatic injury
from sulfamethoxazole-trimethoprim40 and the prescribing information
for these drugs states: “Fatalities associated with hepatic necrosis
have occurred; discontinue use at first sign of rash or signs of serious
adverse reactions.”94-96. Blood dyscrasias such as aplastic anemia
agranulocytosis, neutropenia, and thrombocytopenia have been
associated with the suflonamides.90,97
Hypoglycemia, hyponatremia, and hyperkalemia have been reported
with the use of sulfamethoxazole-trimethoprin in patients who are
elderly, have hepatic or renal impairment, are malnourished, or
received high doses of the drug.90,98-100
Sulfonamide Allergy
Non-antibiotic sulfonamide drugs such as COX-2 non-steroidal antiinflammatories, diuretics, and sulfonylureas and drugs and food
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products that contain sulfur or sulfites are in common use. There is no
cross-reactivity between sulfonamide antibiotics and sulfur or
sulfites101 and there is no convincing evidence of cross-reactivity
between sulfonamide antibiotics and non-antibiotic sulfonamides.102-107
Because of structural differences and differences in metabolic
pathways, prescribing non-antibiotic sulfonamide drugs such as
celecoxib, furosemide, and glyburide for patients who have a sulfa
allergy is unlikely to cause an allergic response. However, it would be
prudent to obtain a detailed history of the patient’s allergic response to
sulfonamide antibiotics and consider the risk and benefits of using a
non-antibiotic sulfonamide drug if the patient has a sulfa allergy.
Labeled Uses
Sulfadiazine
Adjunctive treatment in toxoplasmosis with pyrimethamine is FDA
approved in ages ≥2 months and adults (it may be used in ages <2
months for treatment of congenital toxoplasmosis). Treatment is
generally for chancroid, trachoma, inclusion conjunctivitis, urinary
tract infections, and nocardiosis.
Treatment and prophylaxis of meningococcal meningitis, treatment of
H. influenza meningitis, prophylaxis of rheumatic fever, prophylaxis in
patients who are allergic to penicillin, and treatment of uncomplicated
attack of malaria due to chloroquine-resistant Plasmodium falciparum.
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Sulfamethoxazole-trimethoprin
Oral: Treatment of urinary tract infections, acute otitis media, and
acute exacerbations of chronic bronchitis due to susceptible strains of
H. influenzae or S. pneumoniae. Treatment and prophylaxis of
Pneumocystis pneumonia, and enteritis.
Intravenously: Treatment of Pneumocystis pneumonia, enteritis
caused by Shigella flexneri or Shigella sonnei, and severe or
complicated urinary tract infections.
Sulfur and sulfacetamide
Treatment of acne vulgaris, acne rosacea, and seborrheic dermatitis
Sulfacetamide topical:
Acne (lotion, topical suspension) - Treatment of acne vulgaris.
Bacterial infections (cream, wash, lotion and foam) - Treatment of
bacterial infections of the skin.
Scaling dermatoses (cream, shampoo, wash, lotion and foam) Treatment of scaling dermatoses such as seborrheic dermatitis and
seborrhea sicca (dandruff).
Quinolones
The quinolone antibiotics are available as IV solutions, oral tablets and
suspensions, otic drops, and ophthalmic drops and ointments. The
ophthalmic and otic preparations will not be discussed in detail.
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Table 6: Quinolone Antibiotics
Ciprofloxacin
Gatifloxacin
Gemifloxacin
Levofloxacin
Moxifloxacin
Norfloxacin
Ofloxacin
Mechanism of Action
The quinolone antibiotics inhibit bacterial DNA recombination, repair,
transcription, and transposition.
Administration
The IV quinolones should be infused slowly. Oral quinolones each have
specific administration cautions.
Adverse Effects/Warnings
The prescribing information for these drugs notes that hepatotoxicity
has been reported from the use of quinolones. Mild and transient
elevations of serum aminotransferases are a common side effect of the
quinolones108 and hepatic necrosis and toxic hepatitis have been
reported after the use of ciprofloxacin.108
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All of the quinolones have been noted to cause hypoglycemia and
hyperglycemia.109-112 This effect appears to be dose-related109 and
elderly patients and patients who have diabetes or renal failure are
most at risk,113,114 but dysglycemia has been reported after use of
levofloxacin and moxifloxacin in healthy patients.111,112
A U.S. boxed warning is included in the prescribing information for all
of the quinolones regarding the use of these drugs in patients who
have myasthenia gravis, and states: “May exacerbate muscle
weakness related to myasthenia gravis. Cases of severe exacerbations,
including the need for ventilatory support and deaths have been
reported; avoid use in patients with myasthenia gravis.” This warning
is supported by case reports.115,116
Prolongation of the QT interval of the heart is a documented side effect
of the quinolones117 and prescribing information warns that these
drugs “… may prolong QT interval; avoid use in patients with a history
of QT prolongation, uncorrected hypokalemia, hypomagnesemia, or
concurrent administration of other medications known to prolong the
QT interval…”114 QT prolongation is a recognized risk factor for
torsades de pointes (TDP) and the concern is that QT prolongation
caused by the quinolones can initiate this deadly arrhythmia.
Drug information sources note that drugs such as levofloxacin “…
prolong the QT interval and are associated with the risk of TDP, even
when taken as directed in official labeling.”71 However, the risk for TDP
caused by a quinolone appears to be very low,117 and TDP caused by a
quinolone and preceded by QT prolongation is far more likely to occur
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if other risk factors are present, including but not limited to, advanced
age, bradycardia, cardiovascular disease, congestive heart failure,
female gender, electrolyte abnormalities, and left ventricular
hypertrophy.
Tendinitis and/or tendon rupture, most often in the Achilles tendon,
has been associated with the use of quinolones118-120 and the FDA
requires a Boxed Warning regarding this injury to be included in
prescribing information for these drugs.118 The estimated occurrence of
tendinitis and tendon rupture caused by the quinolones is 0.14%4%.118
Ciprofloxacin
Avoid administering ciprofloxacin with antacids. Give immediate
release ciprofloxacin and extended release Cipro at least 2 hours
before or 6 hours after antacids or products containing calcium, iron,
or zinc. The oral suspension should not be given through a feeding
tube. If immediate release tablets are given through a feeding tube,
the feeding tube should be flushed before and after administration.
Tube feedings should be held at least 1 hour before and 2 hours after
administration. Good hydration should be maintained.
Gemifloxacin
Gemifloxacin may be given with or without food, milk, or calcium
supplements. Gemifloxacin should be taken 3 hours before or 2 hours
after supplements and/or multivitamins containing iron, magnesium,
or zinc. Good hydration should be maintained.
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Levofloxacin
The oral solution should be administered on an empty stomach, 1 hour
before or 2 hours after a meal. Oral levofloxacin should be taken 2
hours before or 2 hours after multivitamins, antacids, or other
products containing aluminum, iron, magnesium, or zinc. Good
hydration should be maintained.
Moxifloxacin
Moxifloxacin can be taken with or without food, but it should be taken
4 hours before or 8 hours after multivitamins, antacids, or other
products containing aluminum, iron, magnesium, or zinc. Good
hydration should be maintained.
Norfloxacin
Antacids, sucralfate, and multivitamins or other products containing
aluminum, iron, magnesium, or zinc should not be given with 2 hours
of an oral dose of norfloxacin. Norfloxacin should be taken 1 hour
before or 2 hours after a meal or dairy products.
Ofloxacin
Should not be taken within 2 hours of food or any antacids, which
contain aluminum, magnesium, or zinc.
Labeled Uses
Ciprofloxacin
Children: Complicated urinary tract infections and pyelonephritis due
to E. coli. Although effective, ciprofloxacin is not the drug of first
choice in children.
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Children and Adults: To reduce incidence or progression of disease
following exposure to aerosolized Bacillus anthracis; prophylaxis and
treatment of plague, including pneumonic and septicemic plague, due
to Yersinia pestis.
Adults: Treatment of the following infections when caused by
susceptible bacteria: urinary tract infections; acute uncomplicated
cystitis in females and chronic bacterial prostatitis; lower respiratory
tract infections (including acute exacerbations of chronic bronchitis);
acute sinusitis, skin and skin structure infections, bone and joint
infections, complicated intra-abdominal infections (in combination with
metronidazole), infectious diarrhea, typhoid fever due to Salmonella
typhi (eradication of chronic typhoid carrier state has not been
proven), uncomplicated cervical and urethra gonorrhea (due to N.
gonorrhoeae), nosocomial pneumonia, and as empirical therapy for
febrile neutropenic patients (in combination with piperacillin).
Gatifloxacin
Treatment of bacterial conjunctivitis
Gemifloxacin
Treatment of acute exacerbation of chronic bronchitis and communityacquired pneumonia, including pneumonia caused by multidrugresistant strains of S. pneumoniae.
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Levofloxacin
Treatment of community-acquired pneumonia, including multidrug
resistant strains of S. pneumoniae, nosocomial pneumonia, chronic
bronchitis (acute bacterial exacerbation), acute bacterial rhinosinusitis,
prostatitis, urinary tract infection (uncomplicated or complicated),
acute pyelonephritis, skin or skin structure infections (uncomplicated
or complicated), to reduce incidence or disease progression of
inhalational anthrax (post-exposure), for prophylaxis and treatment of
plague (pneumonic and septicemic) due to Y. pestis. Levofloxacin
ophthalmic is used to treat bacterial conjunctivitis.
Moxifloxacin
Treatment of mild to moderate community-acquired pneumonia,
including multidrug-resistant Streptococcus pneumoniae, acute
bacterial exacerbation of chronic bronchitis, acute bacterial sinusitis,
complicated and uncomplicated skin and skin structure infections,
complicated intra-abdominal infections, prophylaxis and treatment of
plague (pneumonic and septicemic plague) due to Yersinia pestis.
Moxifloxacin ophthalmic is used to treat bacterial conjunctivitis.
Norfloxacin
Treatment of uncomplicated and complicated urinary tract infections
caused by susceptible gram-negative and gram-positive bacteria,
sexually-transmitted diseases caused by N. gonorrhoeae, and
prostatitis due to E. coli.
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Ofloxacin
Treatment of acute exacerbations of chronic bronchitis, communityacquired pneumonia, skin and skin structure infections
(uncomplicated), urethral and cervical gonorrhea (acute,
uncomplicated), urethritis and cervicitis (nongonococcal), mixed
infections of the urethra and cervix, pelvic inflammatory disease
(acute), cystitis (uncomplicated), urinary tract infections
(complicated), and prostatitis. Ofloxacin ophthalmic is used to treat
conjunctival and/or corneal bacterial infections. Ofloxacin otic is used
to treat acute otitis media externa, chronic suppurative otitis media,
and otitis externa.
Tetracyclines
The tetracycline antibiotics include demeclocycline, doxycycline,
minocycline, and tetracycline. The tetracyclines are available as oral
capsules, solutions, suspensions, and tablets and as solutions that can
be given IV.
Mechanism of Action
The tetracyclines inhibit bacterial cell wall synthesis.
Administration
Tetracyclines should not be taken with antacids, calcium supplements,
or multivitamins as these will decrease the absorption of the
tetracyclines. The oral tetracyclines should be taken with at least 8
ounces of water and the patient should remain upright for 30 minutes
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after administration in order to avoid esophageal irritation. Minocycline
may be taken with food; the other tetracyclines should be taken 1-2
hours after a meal.
Adverse Effects/Warnings
Tetracyclines should be used cautiously and dose adjustments should
be made if the patient has renal impairment. Tetracyclines are
classified as an FDA pregnancy risk category D drug: there is positive
evidence of risk to the fetus and these drugs should not be used
during pregnancy unless the benefit outweighs the risk.
Hyperpigmentation and discoloration of the teeth and disruption of
enamel formation are a well-documented and very common (up to
92% in some studies) adverse effect of tetracycline that can occur if
tetracycline is given when teeth are developing;121,122 use of these
drugs should be avoided in children <8 years of age. The level of risk
for this adverse effect after administration of the other tetracyclines is
not known.121
Photosensitivity is a common adverse effect caused by
tetracyclines.123-125 It is usually manifested by erythema similar in
appearance to sunburn and discontinuation of the drug is typically the
only treatment that is needed.125 Prolonged use may cause C. difficileassociated diarrhea or pseudomembranous colitis. Diabetes insipidus is
a common adverse effect of demeclocycline.126,127
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Increased intracranial pressure has been commonly reported as an
adverse effect of the tetracyclines.128,129 This will usually resolve after
the drug has been discontinued. Serious sequelae from increased
intracranial pressure are rare and more common in obese females of
childbearing age and/or who have a history of intracranial
hypertension.130
Labeled Uses
Demeclocycline
Treatment of urinary tract and respiratory tract infections caused by
susceptible bacteria. This drug is not often prescribed; the other
tetracyclines are preferred.
Doxycycline
Treatment of patients infected by susceptible Rickettsia, Chlamydia,
Chlamydophila, and Mycoplasma. It is used as a malaria prophylaxis.
It is prescribed to treat patients who have anthrax infection,
Clostridium infection if the patient is allergic to penicillin, communityacquired pneumonia, gonorrhea and syphilis, and infections with
uncommon organisms such as Bartonella bacilliformis, Borrelia
recurrentis, Brucella spp, Campylobacter fetus, Francisella tularensis,
Haemophilus ducreyi, Klebsiella granulomatis, Ureaplasma
urealyticum, Vibrio cholerae, and Yersinia pestis (plague).
Doxycyline can also be used to treat severe acne, intestinal amebiasis,
and Q fever.
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Minocycline
Treatment of acne, actinomycosis, anthrax, and asymptomatic carriers
of Neisseria meningitides. Treatment of Campylobacter fetus
infections, cholera, Clostridium spp infections, gram-negative
infections, listeriosis, meningitis, ophthalmic infections, relapsing fever,
respiratory tract infections, rickettsial infections, sexually transmitted
infections, skin and skin structure infections, urinary tract infections,
Vincent infection, yaws, and zoonotic infections.
Tetracycline
Treatment of infections caused by Chlamydia, Mycoplasma, and
Rickettsia. Treatment of bacterial infections caused by susceptible
gram-negative and gram-positive bacteria. Tetracycline can also be
used to treat patients who have acne, exacerbations of chronic
bronchitis, sexually transmitted diseases if the patient is allergic to
penicillin, and patients who have tularemia. Tetracycline is used with
other drugs to eradicate H pylori.
Miscellaneous Antibiotics:
Metronidazole And Nitrofurantoin
Metronidazole
Mechanism of Action
Metronidazole inhibits bacterial protein synthesis by disrupting DNA
structure.
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Administration
Extended release metronidazole tablets should be taken 1 hour before
or 2 hours after a meal. Patients taking metronidazole should avoid
drinking ethanol during therapy and for 3 days after the last dose.
Concomitant use of ethanol and metronidazole has been reported to
cause a disulfiram-like reaction. Disulfiram, commonly known by the
trade name Antabuse, interferes with the metabolism of ethanol by
inhibiting the activity of acetaldehyde dehydrogenase and the
accumulation of acetaldehyde causes diaphoresis, headache, facial
flushing, nausea, palpitation, and vomiting. These effects explain why
Antabuse is used as a treatment for an alcohol use disorder.
Metronidazole is thought to have a similar inhibitory effect on
acetaldehyde dehydrogenase and there have been case reports
documenting a disulfiram-like reaction when ethanol and
metronidazole are taken together, but there is some doubt that there
is a true-cause and effect relationship.131,132 Metronidazole is available
as oral capsules, regular and extended release, and as an IV solution.
Adverse Reactions/Warnings
U.S. Boxed Warning: Possibly carcinogenic based on animal data.
Headache, nausea, and vaginitis are common adverse effects of
metronidazole.
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Labeled Uses
Amebiasis, anaerobic bacterial infections (caused by Bacteroides spp,
including the B. fragilis group), bacterial septicemia, bacterial
vaginosis, bone and joint infections, CNS Infections including
meningitis and brain abscess, endocarditis, intra-abdominal infections,
lower respiratory tract infections, skin and skin structure infections,
surgical prophylaxis for colorectal surgery, and trichomoniasis.
Nitrofurantoin
Mechanism of Action
Nitrofurantoin inhibits bacterial protein and cell wall synthesis, disrupts
bacterial DNA and RNA activity, and inhibits aerobic metabolism.
Administration
Nitrofurantoin should be taken with meals.
Adverse Effects/Warnings
Nitrofurantoin is contraindicated if the patient’s creatinine clearance is
<60 mL/min. Nitrofurantoin is contraindicated in pregnant patients
who are between 38-42 weeks gestation and during labor and delivery,
and it is contraindicated in neonates <1 month. In all of these
circumstances immature erythrocytes may be at risk for hemolysis,
and the drug should be used with caution in patients who are G6PD
(an enzyme known to protect red blood cells) deficient.
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Labeled Uses
Acute cystitis in patients ≥12 years and treatment of urinary tract
infections.
Guideline For Administering Antibiotics
Safely administering antibiotics requires knowing the risks and hazards
that are common to all antibiotics and the specific risks and hazards of
each drug. Of course, given the number and complexity of reported
adverse effects and cautions for all the antibiotics and for the specific
drugs this can seem to be an impossible task but it is actually a simple
process. The risks and hazards common to antibiotics are summarized
below, and information about the risks and hazards particular to each
antibiotic is widely available.
Risks and Hazards of Antibiotics
Allergic Reactions
All of the antibiotics can cause allergic reactions and cross-reactivity
between antibiotics of the same class and antibiotics of different
classes can occur. However, the β-lactam antibiotics are far more likely
to cause an allergic reaction than other antibiotics and even with those
drugs the risk is not high and cross-reactivity between antibiotics is
unusual.
Allergic reactions cannot be totally prevented. However, using the
following approach can diminish the risk of their occurrence and any
potential harm:
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1. Always ask the patient if he/she is allergic to any antibiotics
and/or checking the medication record for documentation of an
antibiotic allergy, which should be done before giving the patient
a first dose.
2. Reading the prescribing information.
3. Knowing the names of the classes of antibiotics. If the
prescribing information notes that an antibiotic is contraindicated
if the patient is allergic to other cephalosporins or carbapenems,
this information would be of no value if the clinician did not know
what those terms meant.
4. Realizing that allergic reactions can range from mild to life
threatening and that they can be immediate and delayed. Many
people assume that allergic reactions happen immediately but
this is not true.
5. Knowing that cross-reactivity can occur between classes of
antibiotics.
Gastrointestinal Adverse Effect
Mild and temporary gastrointestinal problems such as nausea and
diarrhea are common side effects of all oral antibiotics, but serious C.
difficile infections caused by alteration of the gut micro-flora are
possible and these infections cause diarrhea, as well. Serious antibiotic
associated diarrhea should be suspected if:
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1. the onset occurs while the patient is hospitalized;
2. the patient is elderly and/or has a compromised immune system
or is receiving a proton pump inhibitor;
3. the patient has a fever and/or has frequent, copious, watery
stools; and,
4. the patient has had C. difficile-associate diarrhea before;
remember that C. difficile-associated diarrhea can begin weeks
after the last dose of an antibiotic.
Hepatic Adverse Effects
The prescribing information for essentially every antibiotic notes that
caution should be used in patients with preexisting liver disease or
hepatic impairment and that serious liver injury, including irreversible
drug-induced hepatitis and fulminant hepatic failure (sometimes fatal),
have been reported with use. However, although drug-induced liver
damage is relatively common to some of the antibiotics, serious
hepatic damage is not.
Safe administration of antibiotics in terms of hepatic injury and/or
impairment requires the clinician to: 1) observe the patient for signs
and symptoms of liver damage; and, 2) be aware that if the patient
has pre-existing liver impairment the metabolism of the antibiotic may
be decreased, increasing blood levels and the risk for antibiotic
adverse effects.
Nephrotoxicity
It’s important for the clinician to be aware that: 1) nephrotoxicity is a
possible adverse effect of antibiotics and that impaired renal function
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can decrease excretion of antibiotics; 2) some of the cephalosporins,
the carbapenems, and the glycopeptides are especially likely to cause
kidney damage; 3) patients at risk for nephrotoxicity must be
identified, i.e., the elderly, and patients who are dehydrated, febrile,
and have renal impairment; and, 4) it’s important to monitor the
patient’s intake and output, BUN, creatinine and, if indicated, the peak
and trough levels of the drug.
Administration
There are exceptions but most IV doses of antibiotics should be
administered slowly; rapid infusion can cause seizures. Some of the IV
antibiotics have sodium as part of their formula, an obvious hazard for
certain patients. Finally, many of the oral antibiotics have specific
requirements in terms of co-administration with food, antacids, or
other medications.
If clinicians are unfamiliar with an antibiotic, they should check the
prescribing information before giving it to see what if any dietary
restrictions apply.
Pregnancy
The FDA has 5 categories of risk that can be assigned to a drug to
indicate its potential for harm to a fetus. This is outlined in the table
below.
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Table 7: Pregnancy Risk Categories
Category A:
Adequate, well-controlled studies have failed to demonstrate a risk to the
fetus during the first trimester of pregnancy, and there is no evidence of
risk in later trimesters.
Category B:
Animal reproduction studies have failed to demonstrate a risk to the fetus
and there are no adequate and well-controlled studies in pregnant women.
Category C:
Animal reproduction studies have shown an adverse effect on the fetus and
there are no adequate and well-controlled studies in humans, but potential
benefits may warrant use of the drug in pregnant women despite potential
risks.
Category D:
There is positive evidence of human fetal risk based on adverse reaction
data from investigational or marketing experience or studies in humans,
but potential benefits may warrant use of the drug in pregnant women
despite potential risks.
Category X:
Studies in animals or humans have demonstrated fetal abnormalities
and/or there is positive evidence of human fetal risk based on adverse
reaction data from investigational or marketing experience, and the risks
involved in use of the drug in pregnant women clearly outweigh potential
benefits.
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Table 8: Category B Antibiotics
Cephalosporins
Doripenem
Ertapenem
Meropenem
Vancomycin (Oral)
Azithromycin
Erythromycin
Fidaxomicin
Telitromycin
Clindamycin
Pencillins
Metronidazole
Nitrofurantoin
Table 9: Category C Antibiotics
Aminoglycosides
Imipenem
Dalbavancin
Oritavancin
Telavancin
Vancomycin (IV)
Clarithromycin
Lincomycin
Sulfaziadine
Sulfur-sulfaziadine
Sulfacetamide (Topical)
Quinolones
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Patient Teaching
Patient teaching is essential for the safe and effective use of
antibiotics. The effectiveness of these drugs can be diminished by poor
patient compliance and improper use. The following points should be
discussed with the patient and his/her understanding of them
evaluated.

What is this medicine for?

Are there any restrictions with this drug? For example,
could this make me drowsy so I should not drive after
taking the drug?

When should I take the medicine?

Should I take the medicine with food or on an empty
stomach?

If the medication must be taken on an empty stomach,
how long before and after a meal should it be taken?

What are the common side effects with this medicine?
If I am having a side effect when should I call the
prescriber?

Are there any necessary follow-ups either by exam or
laboratory evaluation for monitoring this medicine?

Can this medicine interact with any of my other
medicines?

Are there over-the-counter drugs or foods I should
avoid while I am taking this medication?

Are there any severe risks with this medicine?

What should I do if I miss a dose of the medicine?

Can I drink alcohol while taking this medicine?
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Summary
Common antibiotics used in the United States, specifically the
aminoglycoside, carbapenem, cephalosporin, glycopeptide,
lincosamide, macrolide, penicillin, quinolone, sulfonamide, and
tetracycline antibiotics, and metronidazole and nitrofurantoin, have
been reviewed primarily in terms of drug indication, administration and
adverse effects/warnings. Additionally, labeled use of various antibiotic
drug classes and use of specific drugs have been summarized in terms
of their antimicrobial actions. Specific patient populations and risk
factors were raised as important considerations to ensure the
appropriate use of a drug.
Importantly, clinicians are reminded that antibiotic resistance has
become a long-standing problem. Patient history taking and education
are essential before starting antibiotic treatment to optimize efficacy of
the drug to kill an offending organism and to avoid the development of
a resistant strain. Microorganisms that are resistant to the available
antibiotics have become more common and infections caused by these
resistant strains can be quite difficult to treat and have serious
implications for the patient and the health care system.
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1. Antibiotic-associated diarrhea
a. can have a delayed onset and cause serious complications.
b. occurs after the first dose and is always mild and self-limiting.
c. only occurs in women > age 60.
d. typically affects hospitalized neonates.
2. Allergic reactions to antibiotics
a. always happen within one hour after a dose.
b. can be delayed in onset.
c. are always severe and life-threatening.
d. only occur in people who have a compromised immune
system.
3. True or false: Someone who is allergic to penicillin may be
allergic to cephalosporins.
a. True
b. False.
4. Patients who are receiving antibiotic therapy should be monitored
for
a. osteoporosis.
b. polycythemia.
c. diabetes mellitus.
d. nephrotoxicity.
5. Which of these antibiotics is well known for causing ototoxicity?
a. Carbapenems.
b. Metronidazole.
c. Aminoglycosides.
d. Quinolones.
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6. Therapy with quinolone antibiotics can place the patient at risk
for
a. QTc prolongation
b. hemolytic anemia.
c. ototoxicity.
d. tendon rupture.
7. Which of the following is a Boxed Warning for Levofloxacin?
a. Hemolytic anemia.
b. Tendon rupture.
c. Seizures.
d. Ototoxicity.
8. Which of the following is well-documented adverse effect of the
tetracyclines?
a. Tendon rupture.
b. Ototoxicity.
c. Teeth staining.
d. Torsades de Pointes.
9. A patient who is allergic to a sulfonamide antibiotic
a. should never take a food or drug that contains sulfites.
b. should never take a non-antibiotic sulfonamide.
c. will be allergic to the cephalosporins.
d. may be allowed to take a non-antibiotic sulfonamide.
10. True or false: Patients taking metronidazole can safely drink
alcohol.
a. True.
b. False.
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11. Clostridium-difficile-associated diarrhea
a. is a major risk of antibiotic use.
b. is primarily a nosocomial infection.
c. may cause death and sepsis.
d. All of the above.
12. Vancomycin IV is used to treat patients who have
a. Staphylococcal or Streptococcal infections.
b. C. difficile-associated diarrhea.
c. enterocolitis.
d. necrosis.
13. Rapid IV administration of a glycopeptides antibiotic can cause
skin rashes and irritation known as
a. Torsade de Pointes.
b. nosocomial infection.
c. “red man syndrome.”
d. Stevens-Johnson syndrome.
14. Anaphylaxis, an allergic reaction caused by antibiotics, i.e.,
penicillins, is more likely caused by
a. topical administration.
b. oral administration.
c. parenteral administration.
d. administration by gastric feeding tube.
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15. Patients administered oritavancin should be monitored for signs
and symptoms of
a. Stevens-Johnson syndrome.
b. osteomyelitis.
c. enterocolitis.
d. tendon rupture.
16. Extravasation of ______________ can cause tissue necrosis.
a. nafcillin
b. vancomycin.
c. sulfacetamide topical.
d. answers a and b.
17. Which antibiotics have a higher risk of increasing seizures in
patients?
a. Penicllins
b. Glycopeptides
c. Valproic acid
d. Tetracyclines
18. Sulfamethoxazole-trimethoprim is one of the top three causes
of drug-induced
a. ototoxicity.
b. seizures.
c. severe colitis.
d. liver injury.
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19.
Tetracyclines should not be taken with antacids, calcium
supplements, or multivitamins as these will
a. increase the risk of osteomyelitis.
b. increase the risk of bleeding.
c. always cause nausea.
d. decrease the absorption of the tetracyclines.
20. True or false: Antibiotics are the most common cause of druginduced liver damage.
a. True.
b. False.
Correct Answers:
1.
A
11. D
2.
B
12. A
3.
A
13. C
4.
D
14. C
5.
C
15. B
6.
A
16. D
7.
B
17. A
8.
C
18. D
9.
D
19. D
10. B
20. A
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