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Chapter 39
Antibiotics Part 2
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Antibiotic Therapy: Concepts
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Multidrug resistance
Therapeutic drug monitoring
Minimum inhibitory concentration (MIC)
Time-dependent killing
Concentration-dependent killing
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Once-daily dosing vs. multidaily dosing
Peak and trough blood levels
Synergistic effects
Postantibiotic effect (PAE)
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Multidrug-Resistant Organisms
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Organisms that are resistant to one or more
classes of antimicrobial drugs
Methicillin-resistant Staphylococcus aureus
(MRSA)
Vancomycin-resistant Enterococcus (VRE)
Organisms producing extended-spectrum betalactamases (ESBLs)
Organisms producing Klebsiella pneumoniae
carbapenemase (KPC)
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Aminoglycosides
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Natural and semisynthetic
Produced from Streptomyces
Poor oral absorption; no PO forms (exception
neomycin)
Very potent antibiotics with serious toxicities
Bactericidal; prevent protein synthesis
Kill mostly gram-negative bacteria; some
gram-positive
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Aminoglycosides (cont’d)
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gentamicin
neomycin (Neo-fradin)
tobramycin (TOBI)
amikacin
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Aminoglycosides: Indications
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Used to kill gram-negative bacteria, such as
Pseudomonas spp., Escherichia coli, Proteus
spp., Klebsiella spp., Serratia spp.
Often used in combination with other antibiotics
for synergistic effects
Used for certain gram-positive infections that
are resistant to other antibiotics
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Aminoglycosides: Indications
(cont’d)
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Aminoglycosides are poorly absorbed through
the GI tract, and given parenterally
Exception: neomycin
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Given orally to decontaminate the GI tract before
surgical procedures
Also used as an enema for this purpose
Used to treat hepatic encephalopathy
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Aminoglycosides: Adverse Effects
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Cause serious toxicities
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Nephrotoxicity (renal damage)
Ototoxicity (auditory impairment and vestibular
impairment [eighth cranial nerve])
Must monitor drug levels to prevent toxicities
Minimum inhibitory concentration (MIC)
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Aminoglycosides:
Adverse Effects (cont’d)
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Ototoxicity and nephrotoxicity are the most
significant
Headache
Paresthesia
Fever
Superinfections
Vertigo
Skin rash
Dizziness
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Quinolones
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Also called fluoroquinolones
Excellent oral absorption
Absorption reduced by antacids
Effective against gram-negative organisms and
some gram-positive organisms
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Quinolones (cont’d)
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ciprofloxacin (Cipro)
norfloxacin (Noroxin)
levofloxacin (Levaquin)
moxifloxacin (Avelox)
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Quinolones:
Mechanism of Action
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Bactericidal
Alter DNA of bacteria, causing death
Do not affect human DNA
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Quinolones: Indications
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Gram-negative bacteria such as Pseudomonas
Complicated urinary tract, respiratory, bone and
joint, GI, skin, and sexually transmitted infections
Anthrax (ciproflaxin)
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Classroom Response Question
During intravenous quinolone therapy in an 88year-old patient, which potential problem is of most
concern when assessing for adverse effects?
A. Hepatotoxicity
B. Rhabdomyolysis
C. Tendon rupture
D. Nephrotoxicity
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Quinolones: Adverse Effects
Body System
CNS
GI
Cardiac
Adverse Effects
Headache, dizziness,
insomnia, depression,
restlessness, convulsions
Nausea, vomiting, diarrhea,
constipation, thrush, increased
liver function studies, others
Prolonged QT interval
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Quinolones:
Adverse Effects (cont’d)
Body System
Integumentary
Other
Adverse Effects
Rash, pruritus, urticaria,
flushing
Ruptured tendons,*
tendonitis,* fever, chills,
blurred vision, tinnitus
*Black box warning: Increased risk of tendonitis and tendon rupture
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Miscellaneous Antibiotics
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clindamycin (Cleocin)
linezolid (Zyvox)
metronidazole (Flagyl)
nitrofurantoin (Macrodantin)
quinupristin/dalfopristin (Synercid)
daptomycin (Cubicin)
vancomycin (Vancocin)
colistimethate (Coly-Mycin)
telavancin (Vibativ)
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Miscellaneous Antibiotics (cont’d)
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clindamycin (Cleocin)
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Used for chronic bone infections, GU infections,
intraabdominal infections, other serious infections
May cause pseudomembranous colitis (also known
as antibiotic-associated colitis, Clostridium difficile
diarrhea, or C. difficile infection)
Potential interaction with vecuronium
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Miscellaneous Antibiotics (cont’d)
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linezolid (Zyvox)
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New class: oxazolidinones
Used to treat vancomycin-resistant Enterococcus
faecium (VREF, VRE), hospital-acquired, and skin
structure infections, including those with MRSA
May cause hypotension, serotonin syndrome if taken
with SSRIs, and reactions if taken with tyraminecontaining foods
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Classroom Response Question
A patient is prescribed linezolid (Zyvox) to treat
hospital-acquired pneumonia. It is most important
for the nurse to determine if the patient is also
taking which medication?
A. A diuretic
B. A selective serotonin reuptake inhibitor
C. A cardiac glycoside
D. A thyroid replacement drug
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Miscellaneous Antibiotics (cont’d)
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metronidazole (Flagyl)
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Used for anaerobic organisms
 Intraabdominal and gynecologic infections
 Protozoal infections
 Several drug interactions
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Miscellaneous Antibiotics (cont’d)
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nitrofurantoin (Macrodantin)
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Primarily used for urinary tract infections (UTIs) (E.
coli, Staphylococcus aureus, Klebsiella spp.,
Enterobacter spp.)
Use carefully if renal function is impaired
Drug concentrates in the urine
May cause fatal hepatotoxicity
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Miscellaneous Antibiotics (cont’d)
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quinupristin/dalfopristin (Synercid)
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30:70 combination, work synergistically
Used for bacteremia and infections caused by
vancomycin-resistant Enterococcus (VRE) and for
treatment of complicated skin and skin structure
infections caused by S. pyogenes and S. aureus,
including MRSA
May cause arthralgias, myalgias
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Miscellaneous Antibiotics (cont’d)
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vancomycin (Vancocin)
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Treatment of choice for MRSA and other grampositive infections
 Oral vancomycin is indicated for the treatment of
antibiotic-induced colitis (C. difficile) and for the
treatment of staphylococcal enterocolitis
 Must monitor blood levels to ensure therapeutic levels
and prevent toxicity
 May cause ototoxicity and nephrotoxicity
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Classroom Response Question
A 58-year-old man is receiving vancomycin as part
of the treatment for a severe bone infection. After
the infusion, he begins to experience some itching
and flushing of the neck, face, and upper body. He
reports no chills or difficulty breathing. The nurse
should suspect:
A. an allergic reaction has occurred.
B. an anaphylactic reaction is about to occur.
C. the medication will not be effective for the bone
infection.
D. the IV dose may have infused too quickly.
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Miscellaneous Antibiotics (cont’d)
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vancomycin (Vancocin) (cont’d)
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Red man syndrome may occur
• Flushing/itching of head, neck, face, upper trunk
• Antihistamine may be ordered to reduce these effects
Additive neuromuscular blocking effects in patients
receiving neuromuscular blockers
Should be infused over 60 minutes
Rapid infusions may cause hypotension
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Miscellaneous Antibiotics (cont’d)
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daptomycin (Cubicin)
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Only drug of the new class known as lipopeptides
Mechanism of action is not completely known
Binds to gram-positive cells in a calcium-dependent
process and disrupts the cell membrane potential
Used to treat complicated skin and soft-tissue
infections caused by susceptible gram-positive
bacteria, including MRSA and VRE
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Miscellaneous Antibiotics (cont’d)
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colistimethate (Coly-Mycin)
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Polypeptide antibiotic that penetrates and disrupts the
bacterial membrane of susceptible strains of gramnegative bacterial
Commonly referred to as colistin
Serious adverse effects
Can cause acute respiratory failure when
administered by inhalation
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Miscellaneous Antibiotics (cont’d)
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telavancin (Vibativ)
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Lipoglycopeptide
Indicated for the treatment of skin and skin structure
infections caused by susceptible gram-positive
organisms
Effective against MRSA and VRE
Most common adverse effects include renal toxicity,
infusion-related reactions, and QT prolongation
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Nursing Implications
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Before beginning therapy, assess drug allergies;
hepatic, renal, and cardiac function; and other
lab studies
Be sure to obtain thorough patient health history,
including immune status
Assess for conditions that may be
contraindications to antibiotic use or that may
indicate cautious use
Assess for potential drug interactions
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Nursing Implications (cont’d)
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It is ESSENTIAL to obtain cultures from
appropriate sites BEFORE beginning antibiotic
therapy
Instruct patients to take antibiotics exactly as
prescribed and for the length of time prescribed;
they should not stop taking the medication early
even if they feel better
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Nursing Implications (cont’d)
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Assess for signs and symptoms of
superinfection: fever, perineal itching, cough,
lethargy, or any unusual discharge
For safety reasons, check the name of the
medication carefully because there are many
drugs that sound alike or have similar spellings
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Nursing Implications (cont’d)
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Each class of antibiotics has specific adverse
effects and drug interactions that must be
carefully assessed and monitored
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Classroom Response Question
A group of office workers is concerned because a
package was opened that contained a white
powder substance. There is a concern that the
white powder is anthrax. Which drug does the
nurse anticipate being prescribed for the office
workers?
A. daptomycin (Cubicin)
B. colistimethate (Coly-Mycin)
C. ciprofloxacin (Cipro)
D. quinupristin/dalfopristin (Synercid)
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Nursing Implications (cont’d)
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Monitor for therapeutic effects
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Improvement of signs and symptoms of infection
 Return to normal vital signs
 Negative culture and sensitivity tests
 Disappearance of fever, lethargy, drainage, and
redness
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Monitor for adverse reactions
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