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Chapter 46 Antimicrobial Agents Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 46 Lesson 46.1 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 2 Objectives • Explain the major actions and effects of drugs used to treat infectious diseases • Identify criteria used to select an effective antimicrobial agent • Identify baseline data the nurse should collect on a continual basis for comparison and evaluation of antimicrobial drug effectiveness Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 3 Objectives (cont’d) • Describe the nursing assessments and interventions for the common adverse effects associated with antimicrobial agents: Allergic reaction Direct tissue damage (e.g., nephrotoxicity, ototoxicity, hepatotoxicity) Secondary infection Other considerations, such as photosensitivity, peripheral neuropathy, and neuromuscular blockage Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 4 Objectives (cont’d) • Identify significant data in a patient history that could alert the medical team that a patient is more likely to experience an allergic reaction • Describe basic principles of patient care that can be implemented to enhance an individual’s therapeutic response during an infection Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 5 Antimicrobial Agents • Antibiotics: classified according to type of pathogen they are effective against Antibacterial – bacteria Antifungal – fungal Antiviral – viral • Subdivided by chemical family Penicillins Tetracyclines Aminoglycosides Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 6 Nursing Assessment Before Antimicrobial Therapy • • • • • • • History of current infection Past history Allergies Medication history Physical examination Laboratory and diagnostic testing Identify patients who need prophylactic antibiotic treatment Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 7 Nursing Assessment During Antimicrobial Therapy • Nausea, vomiting, diarrhea; secondary infection; allergies and anaphylaxis • Nephrotoxicity; hepatotoxicity; ototoxicity • Blood dyscrasias; photosensitivity • Proper drug administration Timing: with meals or before or after meals Use of a second drug to prevent excretion Hydration Drug-drug or drug-food interactions Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 8 Chapter 46 Lesson 46.2 Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 9 Objectives • Explain the major actions and effects of drugs used to treat infectious diseases • Review parenteral administration techniques and the procedure for vaginal insertion of drugs • Differentiate between gram-negative and gram-positive microorganisms and between anaerobic and aerobic properties of microorganisms Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 10 Objectives (cont’d) • Develop a plan for implementing patient education for patients receiving Aminoglycosides Carbapenems Cephalosporins Glycylcyclines, ketolides Penicillins, quinolones Streptogramins, sulfonamides Tetracyclines Antifungal and antiviral agents Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 11 Drug Class: Aminoglycosides • Actions Inhibit protein synthesis • Uses Effective against gram-negative organisms that cause urinary infections, meningitis, wound infections, septicemia • Serious adverse effects Ototoxicity; nephrotoxicity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 12 Drug Class: Carbapenems • Actions Inhibit bacterial cell wall synthesis; potent broad-spectrum agents resistant to betalactamase enzymes secreted by bacteria • Uses Treat severe infections by multiresistant organisms • Serious adverse effects Severe diarrhea; dizziness, confusion, seizures Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 13 Drug Class: Cephalosporins • Actions Related to penicillins; inhibit bacterial cell wall synthesis; divided into groups • Uses Treat urinary and respiratory tract infections, abdominal infections, bacteremia, meningitis, osteomyelitis • Common adverse effects Diarrhea; electrolyte imbalance • Serious adverse effects Secondary infections; hepatotoxicity; nephrotoxicity; hypoprothrombinemia Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 14 Drug Class: Glycylcyclines • Drug: tigecycline (Tygacil) • Actions Bind to 30S ribosome, preventing protein synthesis; bacteriostatic • Uses Treat broad-spectrum gram-positive, gramnegative, and anaerobic infections • Common adverse effects Gastric irritation • Serious adverse effects Severe diarrhea; photosensitivity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 15 Drug Class: Ketolides • Drug: telithromycin (Ketek) • Actions Bactericidal, prevent bacterial ribosomes from translating its mRNA into new protein • Uses Treat acute bacterial sinusitis, bronchitis, and lung infections; gram-positive infections • Common adverse effects Gastric irritation • Serious adverse effects Fainting, visual disturbances; hepatotoxicity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 16 Drug Class: Macrolides • Actions Inhibit protein synthesis, bacteriostatic and bactericidal • Uses Treat respiratory, GI tract, skin, and soft tissue infections • Common adverse effects Gastric irritation • Serious adverse effects Severe diarrhea, thrombophlebitis Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 17 Drug Class: Oxazolidinones • Drug: linezolid (Zyvox) • Actions Inhibit protein synthesis in bacterial cells, bactericidal and bacteriostatic • Uses Treat serious or life-threatening infections caused by gram-positive organisms • Common adverse effects Gastric irritation, headaches • Serious adverse effects Severe diarrhea, bone marrow suppression, secondary infections, lactic acidosis, seizures, visual neuropathy Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 18 Drug Class: Penicillins • Actions Inhibit cell wall synthesis, penicillinaseresistant penicillins • Uses Treat middle ear infections, pneumonia, meningitis, urinary tract infections, syphilis, gonorrhea • Common adverse effects Diarrhea, electrolyte imbalance • Serious adverse effects Hepatotoxicity, nephrotoxicity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 19 Drug Class: Quinolones • Actions Subclass known as fluoroquinolones; inhibit activity of DNA gyrase, an enzyme needed for replication of bacteria • Uses Effective against gram-positive and gram-negative bacteria • Common adverse effects Nausea, vomiting, diarrhea, discomfort, dizziness, lightheadedness • Serious adverse effects Photosensitivity, rash, nephrotoxicity, neurologic effects Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 20 Drug Class: Streptogramins • Drug: quinupristin-dalfopristin (Synercid) • Actions Inhibit protein synthesis in bacterial cells • Uses Treat vancomycin-resistant E. faecium (VRE), MRSA • Common adverse effects Pain, infusion site inflammation, nausea, vomiting, anorexia, abdominal cramps, diarrhea • Serious adverse effects Hepatotoxicity, arthralgia, myalgia Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 21 Drug Class: Sulfonamides • Actions Inhibit bacterial biosynthesis of folic acid resulting in cell death • Uses Treat UTIs and otitis media • Common adverse effects Nausea, vomiting, anorexia, diarrhea • Serious adverse effects Rash, pruritus, photosensitivity, hematologic reactions, neurologic CNS effects Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 22 Drug Class: Tetracyclines • Actions Inhibit protein synthesis by bacterial cells • Uses Treat venereal diseases, UTIs, upper respiratory tract infections, pneumonia, and meningitis when penicillin is contraindicated • Common adverse effects Nausea, vomiting, anorexia, abdominal cramps, diarrhea • Serious adverse effects Photosensitivity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 23 Drug Class: Antitubercular Agents • Drug: ethambutol (Myambutol) • Actions Alter cellular RNA synthesis and phosphate metabolism • Uses Treat tuberculosis • Common adverse effects Nausea, vomiting, anorexia, abdominal cramps • Serious adverse effects Confusion, hallucination, blurred vision, redgreen vision changes Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 24 Drug Class: Antitubercular Agents (cont’d) • Drug: isoniazid (INH, Nydrazid) • Actions Disrupt the cell wall and inhibit replication of tuberculosis bacteria • Uses Treat and prevent tuberculosis • Common adverse effects Nausea, vomiting • Serious adverse effects Hepatotoxicity, tingling, numbness of hands and feet, dizziness, ataxia Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 25 Drug Class: Antitubercular Agents (cont’d) • Drug: rifampin (Rifadin) • Actions Prevent RNA synthesis by inhibiting DNAdependent RNA polymerase • Uses Eliminate meningococci and H. influenzae type b, (Hib) from asymptomatic carriers • Common adverse effects Reddish orange secretions • Serious adverse effects Nausea, vomiting, anorexia, abdominal cramps Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 26 Miscellaneous Antibiotics • Aztreonam (Azactam) Inhibits cell wall synthesis, monobactams • Chloramphenicol Inhibits bacterial protein synthesis • Clindamycin (Cleocin, Dalacin C) Inhibits protein synthesis • Daptomycin (Cubicin) Cyclic lipopeptide, binds to bacterial membranes and causes rapid depolarization Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 27 Miscellaneous Antibiotics (cont’d) • Metronidazole (Flagyl) Bactericidal, trichomonacidal, and protozoacidal • Spectinomycin (Trobicin) Inhibits protein synthesis • Tinidazole (Tindamax) Similar to metronidazole • Vancomycin (Vancocin) Prevents synthesis of bacterial cell walls Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 28 Drug Class: Topical Antifungal Agents • Actions Alter permeability of cell membranes causing amino acids and electrolytes to leak out • Uses Treat tinea pedis, tinea cruris, tinea corporis, tinea versicolor, Candida infections • Common and serious adverse effects Irritation, redness, swelling, blistering, oozing Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 29 Drug Class: Systemic Antifungal Agents • Drug: amphotericin B dosage forms • Actions Fungistatic agent; disrupt cell membrane of fungal cells • Uses Treat systemic life-threatening fungal infection • Drug: amphotericin B • Common adverse effects Malaise, fever, chills, headache, nausea, vomiting, thrombophlebitis • Serious adverse effects Nephrotoxicity, electrolyte imbalance Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 30 Drug Class: Systemic Antifungal Agents (cont’d) • Drug: fluconazole (Diflucan) • Actions Chemically related to ketoconazole and itraconazole; inhibit certain metabolic pathways in fungi • Uses Treat meningitis, candidiasis systemic candidiasis • Common adverse effects Nausea, vomiting, diarrhea • Serious adverse effects Rash, hepatotoxicity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 31 Drug Class: Systemic Antifungal Agents (cont’d) • Drug: flucytosine (Ancobon) • Actions Antifungal; thought to inhibit RNA and protein synthesis • Uses Treat candidal septicemia, endocarditis, UTIs, meningitis, pulmonary infections • Common adverse effects Nausea, vomiting, diarrhea • Serious adverse effects Hematologic, rash; hepatotoxicity; nephrotoxicity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 32 Drug Class: Systemic Antifungal Agents (cont’d) • Drug: griseofulvin microsize (Griseofulvin Microsize, Grifulvin V) • Actions Stop cell division and new cell growth • Uses Treat ringworm • Common adverse effects Nausea, vomiting, abdominal cramps • Serious adverse effects Urticaria, rash, pruritus; photosensitivity; confusion, dizziness, secondary infections, nephrotoxicity, hepatotoxicity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 33 Drug Class: Systemic Antifungal Agents (cont’d) • Drug: itraconazole (Sporanox) • Actions Chemically related to fluconazole and ketoconazole; interfere with cell wall synthesis • Use Treat variety of infections such as candidiasis, histoplasmosis, blastomycosis • Common adverse effects Nausea, vomiting • Serious adverse effects Hepatotoxicity; heart failure; pruritus, rash Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 34 Drug Class: Systemic Antifungal Agents (cont’d) • Drug: ketoconazole • Actions Chemically related to fluconazole and itraconazole; interfere with cell wall synthesis • Uses Treat candidiasis, histoplasmosis; topically treat seborrheic dermatitis, etc. • Common adverse effects Nausea, vomiting • Serious adverse effects Hepatotoxicity; pruritus, rash Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 35 Drug Class: Systemic Antifungal Agents (cont’d) • Drug: terbinafine (Lamisil) • Actions Inhibit squalene epoxidase, a key enzyme required for biosynthesis in fungi • Uses Treat onychomycosis of the toenail or fingernail • Serious adverse effects Pruritus, rash, fever, chills; nephrotoxicity, hepatotoxicity; neutropenia, lymphopenia Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 36 Drug Class: NRTI Antiviral Agents • Drug: abacavir (ABC) (Ziagen) • Actions Nucleoside analogue transcriptase inhibitor (NRTI); prevent viral DNA growth • Uses In combination with zidovudine and lamivudine to treat HIV-1 infection • Common adverse effects Diarrhea, nausea, vomiting • Serious adverse effects Abdominal pain, numbness, tingling Hypersensitivity; lactic acidosis; hepatotoxicity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 37 Drug Class: Antiviral Agents • Drug: acyclovir (Zovirax) • Actions Inhibit viral cell replication • Uses Topically used to treat herpes genitalis; orally used to treat recurrent genital herpes; IV to treat herpes simplex type 1 and 2 in immunosuppressed patients • Serious adverse effects Pruritus, rash, burning, hives, diaphoresis, nephrotoxicity, hypotension, confusion Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 38 Drug Class: Antiviral Agents (cont’d) • Drug: atazanavir (Reyataz) • Actions HIV protease inhibitor, prevent maturation of viral particles by inhibiting HIV-1 protease • Uses In combination with other antiretroviral agents to treat HIV-1 infections • Common adverse effects Nausea, vomiting, diarrhea, fat distribution, hyperbilirubinemia • Serious adverse effects Hepatotoxicity, rash, hyperglycemia Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 39 Drug Class: Antiviral Agents (cont’d) • Drug: enfuvirtide (Fuzeon) • Actions New class of antiviral agents interferes with entry of viruses into host cells, inhibits fusion of viral and cellular membranes • Uses Treat HIV-1 infections • Common adverse effects Nausea, vomiting, diarrhea • Serious adverse effects Injection site reactions, pneumonia Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 40 Drug Class: Antiviral Agents (cont’d) • Drug: etravirine (Intelence) • Actions Nonnucleoside reverse transcriptase inhibitor (NNRTI) antiviral agent; inhibit replication of HIV-1 • Uses In combination with other agents that act differently to treat HIV-1 infection • Serious adverse effects Rash Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 41 Drug Class: Antiviral Agents (cont’d) • Drug: famciclovir (Famvir) • Actions Prodrug of penciclovir; inhibit viral cell replication • Uses Treat recurrent infections of genital herpes, acute herpes zoster • Common adverse effects Nausea, vomiting, headache • Serious adverse effects Confusion Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 42 Drug Class: Antiviral Agents (cont’d) • Drug: fosamprenavir (Lexiva) • Actions Prodrug of amprenavir; prevent maturation of viral particles by inhibiting HIV-1 protease • Uses In combination with other antiretroviral agents to treat HIV-1 infections • Common adverse effects Nausea, vomiting, diarrhea, fat distribution • Serious adverse effects Hepatotoxicity, rash, hyperglycemia Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 43 Drug Class: Antiviral Agents (cont’d) • Drug: lamivudine (Epivir) • Actions NRTI that inhibits replication of viruses • Uses In combination with zidovudine to treat HIV-1 infection; chronic hepatitis B associated with active liver inflammation • Serious adverse effects Anemia, granulocytopenia, lactic acidosis, hepatotoxicity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 44 Drug Class: Antiviral Agents (cont’d) • Drug: maraviroc (Selzentry) • Actions Fusion inhibitor antiretroviral agents known as chemokine receptor 5 coreceptor antagonists, block entry of HIV-1 into cells • Uses In combination with other antiviral agents to treat HIV-1 • Common adverse effects GI effects • Serious adverse effects Hepatotoxicity, orthostatic hypotension, infection Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 45 Drug Class: Antiviral Agents (cont’d) • Drug: raltegravir (Isentress) • Actions HIV integrase strand transfer inhibitor, enzyme needed to integrate DNA into the host cell • Uses In combination with other antiviral agents to treat HIV-1 • Common adverse effects Headache, nausea, diarrhea • Serious adverse effects Creatine kinase elevations, myopathy, rhabdomyolysis, hepatotoxicity Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 46 Drug Class: Antiviral Agents (cont’d) • Drug: ribavirin (Virazole, Rebetol, Ribasphere) • Actions: Unknown • Uses In combination with interferon alpha-2b to treat chronic hepatitis C, effective against DNA type viral families, inhibitory activity against RSV, influenza, parainfluenza • Common adverse effects Rash, conjunctivitis • Serious adverse effects Diminishing pulmonary function, anemia Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 47 Drug Class: Antiviral Agents (cont’d) • Drug: zanamivir (Relenza) • Actions Inhibit neuraminidase, an enzyme on the viral cell coat necessary for replication • Uses Uncomplicated acute illness from influenza • Serious adverse effects Asthma, bronchospasm, diminishing pulmonary function, cough, sore throat, fever continuing symptoms • Oseltamivir (Tamiflu) also an agent of this type Mosby items and derived items © 2010, 2007, 2004 by Mosby, Inc., an affiliate of Elsevier Inc. Slide 48