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Factors that effect outcome of therapy
1.Identify the microorganism (by symptoms or cultures)
2.Select the proper antibiotic (Sensitivity)
3.Site of infection
4.Other drugs the patient is receiving
5.Renal and liver function of the patient
Problems in therapy
1.Toxicity to the patient (Nurse must be alert to signs of toxicity)
3.Suprainfection. —Arise during therapy, difficult to treat
More likely with broad spectrum — they kill normal bacteria (Ex. Tetracycline
can cause Candida)
Misuse in Therapy
Antibiotics for viruses
Discontinue drug too soon
Self medication with old or unused portions
Factors related to failure
1.Inadequate blood levels of the treatment drug
2.Too short a period of drug treatment
3.Selection of the wrong treatment agent
4.Resistance to the antimicrobial by the pathogen
5.Failure to use combination drug treatment when indicated
6.Delay in treatment
7.Inadequate body defenses within the host
8.Concomitant or previous treatment by a drug agent antagonist to the action of the
9.Adverse reaction in the host, which requires discontinuation of treatment
10.Noncompliance of patient
Nursing care Assessment
Fever, purulent drainage
Increase WBC, signs of inflammation
Check culture
Monitor V.S.
History of exposure
Pre-existing medical condition
History of allergy
Nursing care Teaching
Review benefits and side effects
Take as long as prescribed. Do not share or save.
Take at evenly spaced intervals
Review restrictions; i.e. refrigeration, take with/without food
Check drug incompatibilities
Tongue may darken, not significant
Oral contraceptives may not be effective during therapy
No alcohol (disulfiram effect)
Nursing care Intervention
Timing is important
Give IV s slowly
Usually orals given between meals
Dispose of carefully to minimize environmental dispersion
Cultures taken before therapy
Watch for adverse reactions
Pharmacodynamics Bacteriostatic.
Prevents microorganism growth by inhibiting the production of folic acid in bacterial cells. Interacts with PABA.
Absorbed readily from the GI tract
Lipid soluble. - < "^y< ^ Lo >V
Distributed readily into body tissues and fluids
Metabolized by the liver
Solubility in urine and rate of excretion enhances by drinking a full glass of water.
Prototype: Bactrim (Septra) (Sulfamethoxazole/Trimethroprim)
Sulphonamides p2
Primarily urinary antiseptics
Secondary: Wide range of gram neg and gram pos bacteria
Adverse reactions
Common: Allergy (rash, fever, Stevens Johnson Syndrome, anaphylaxis,
aplastic anemia, hemolytic anemia)
Crystallizes in kidneys
Long term therapy can lead to Vit K deficiency and aplastic anemia
Can cause hypoglycemia, suppress thyroid hormones, impair liver
function, decrease male fertility
Potentiates the effect of Warfarin (Coumadin)
Trimethoprim can cause bone marrow depression
Sulphonamides p3
Contraindications and Precautions
Easily crosses the placental barrier and is in breast milk
Do not give Bactrim while pregnant (Can use Macrodantin for UT1 until
close to term)
Not used in neonates
Nursing considerations
Take with ample fluids (Drink 1500 ml per day)
Monitor I & O
Monitor renal function
Notify M.D.: decreased urinary output, hematuria, flank pain, rash, unable
to consume adequate oral fluids, Hematologic reaction (sore throat, pallor,
purpura, jaundice, weakness).
Some yellow orange urine and skin discoloration not harmful.
i'hotosensitivity (Wear sunscreen)
Inhibits bacterial enzyme called transpaptidase
Inhibits cell wall synthesis
Osmosis causes explosion of the cell
Exposed bacteria are killed directly by the antibiotic or the host's immune system
Drugs prevent formation of new cell walls, therefore, are effective against actively
multiplying bacteria.
Microorganisms develop penicillinases which render the drug inactive.
Penicillins p2
Absorbed p.o., depends on gastric and intestinal pH, best absorbed with no food.
Distributed in lungs, liver, kidney, muscle, bone and placenta
Metabolized by the liver (short V% life: 30-72 min unless another drug (probenicid,
procaine, benzathine) added to prolong serum concentration
Excreted by kidneys
Penicillins p3
Penicillin resistant staph infections (When resistance to Methicillin occurs then there is also resistence to other penicillins and most other antibiotics — MRSA). Absorbed better parenterally
Adverse Reactions
Allergy : Skin rash to anaphylaxis. Can occur within 10 min. Treat with epinephrine. (3-5% of population) Direct toxicity is low except in neonates GI distress with oral PCN (N/V, diarrhea) Contains enough Na and K to alter electrolytes
Penicillins p4
Contraindications and Precautions
Use caution in patients with decreased renal function
Interacts with several drugs: decrease effect of oral contraceptives and
Nursing considerations
Administer aminoglycoside at least an hour apart from PCN
Observe for 30 minutes after administration
Have epinephrine, corticosteroids, antihistimines available
Monitor Na and K levels
Watch for suprainfection — oral and/or vaginal Candida
Advise patient on oral PCN to take on empty stomach
Give around the clock
Teach signs and symptoms of sensitivity
Teach backup birth control if on oral contracrptives
Similar properties to PCN and therefore have cross sensitivity Four generations:
1. Act primarily against gram pos organisms.
Give if allergic to penicillin.
Examples: Cefzolin (Ancef), Cephalexin (Keflex), Cephadrine (Velosef).
2. For polymicrobial infections: diabetic foot ulcers, nosocomial
Slightly extended activity against gram neg organisms Examples: Cefaclor (Ceclor), Ceftin, Cefuroxime (Zinacef)
3. For gram neg organisms (Pseudomonas)
Distributed to CNS
Watch for pseudomembranous colitis Examples: Cefoperazone (Cefobid), Cefotaxime (Claforan), Ceftazidime (Fortaz), Ceftriaxone (Rocephin).
4. For UTI due toKlebsiella, skin and soft tissue infections, staph and
strep, pneumonia. Example: Cefepime (Maxipime)
Cephalosporins p2
Half life twice as long as PCN
Excretion kidney
Most are given IM or IV
Prototype: Rocephin
Gram neg organisms plus all from Gen 1 & 2. GiveifallergictoPCN.
Adverse reactions
Pseudomembranous colitis (Abd pain, diarrhea)
Pain at injection site
IV phlebitis
GI irritation — diarrhea
Contraindications and Precautions
Nephrotoxic when given with other nephrotoxic drugs: i.e. Gentamycin
Cephalosporins p3
Nursing considerations
IM is painful. Mix with Xylocaine to give IM
Teach patient about hypersensitivity reactions
Teach s /s suprainfection
Take oral drug with food
Avoid alcohol
Monitor BUN and Creatinine levels
Wide range of action for Gram pos. and Gram neg. and organisms not responsive
to other drugs.
Interferes with protein synthesis by microbial ribosomes
Gains access to interior of cell by passive diffusion
Bacteriocidal and bacteriostatic
Classified as either short acting, intermediate acting or long acting
Tetracycline p2
Absorbed from the doudenum
Absorption impaired by food, dairy products, calcium, magnesium and
aluminum laxatives and antacids Distributed widely in body tissues Stored in liver, spleen, bone marrow, bone, and dentin*
*Concentrates in new bone and tooth formation and permanently discolors teeth
Tetracycline p3
Infections from Rikettsia (Rocky Mtn Spotted Fever), tularemia,
brucellosis, Chlamydia
Management of Acne vulgaris and amebiasis
Adverse reactions
N/V, abdominal distress, diarrhea
Rash to anaphylaxis
Staph enterocolitis — bloody diarrhea
Contraindications and Precautions
Not recommended for nursing mothers and children under 8 years old
May be toxic to liver and kidneys
Decreases effectiveness of oral contraceptives
Can sunburn easily
Delays blood coagulation
Tetracycline p4
Nursing considerations
Inspect mouth daily for candiasis
Teach alternate birth control
Recommend sunscreen
Take on an empty stomach with eight ounces of water
Avoid dairy products and antacids
Moderate to serious infections. Control of gram pos. and gram neg. aerobic bacilli
Adverse reactions
Renal toxicity
8th cranial nerve damage with high and/or prolonged therapy
Can lead to permanent deafness Neuromuscular blockade if given immediate post-op. Mixes with general
anesthetics and muscle relaxants to cause respiratoiy difficulty and
irregular heartbeat. Shows little allergic potential but if allergic to one aminoglycoside can be
allergic to others.
Aminoglycosides p2
Contraindications and Precautions
Do not give immediately post op. Potentiates warfarin
Administer at least two hours apart from penicillin Avoid sequential use of different aminoglycosides due to residuals left from previous drugs.
Nursing considerations
Monitor kidney function
Monitor peak and trough levels
Monitor for tinnitis, nausea, decreased equillibrum
Monitor for oliguria
Monitor urinalysis for casts or protein
Administer 2 hours apart from other antibiotics
Interferes with DNA replication
Well absorbed p.o. Highly protein bound
Distributed to body secretions, lymph, peritoneal fluid, csf, bone, skin, muscle,
cartilage, and fat Metabolized in the liver.
Excreted through the kidneys ( 40-50% is excreted unchanged in urine). Halflife4hours
Quinolones p2
Gram neg. and Gram pos. organisms.
Lower urinary and respiratory tract infections, skin, bone, joint, and infectious diarrhea.
Adverse reactions
Most disappear with discontinuation of the drug
GI discomfort, h.a., restlessness, syncope, photosensitivity, blurred vision
Contraindications and Precautions
May damage cartilage — do not give to children.
Do not give with antacids
Take with a full glass of water
Do not give with probenecide — decreases excretion
Nursing considerations
Safety precautions for those exhibiting CNS reactions
Pharmacodynamics Bacteriostatic Inhibits protein synthesis Effective against similar spectrum as penicillin Give if allergic to penicillin
Primarily given p.o. Absorbed in the small intestine. Partially destroyed by
gastric acidity (Has coating— do not crush)
Best given on an empty stomach but ok with food
Distributed to most body tissues except CSF
Metabolized in liver excreted in the bile. Some of the drug is reabsorbed in the
large intestine.
Macrolides p2
Give if allergic to penicillin.
Drug of choice for diphtheria, Legionaire's disease and relapsing UTI's
Adverse reactions
Abd. discomfort.
Transient deafness in the real impaired
Contraindications and Precautions
Caution in patients with biliary and/or hepatic disease (OK with renal
Decreases theophyllin clearance
Nursing considerations
Teach patient s/s of cholestatic/ hepatic disease
Miscellaneous Antibiotics
Inhibit bacterial protein synthesis.
Inhibits binding of ribosomes
Bacteriostatic and/or bacteriocidal depending on drug concentration and
microorganism susceptibility
Effective against aerobic Gram pos cocci and some Gram neg. Natural and acquired resistance exists
Well absorbed from the GI tact. OK with food
Distributed in many tissue. Does not cross blood brain barrier. Crosses placenta
and breast milk. Metabolized in the liver and excreted in the kidneys
Miscellaneous Antibiotics p2
Septicemic infections: Skin, soft tissue, respiratory and intra-abdominal systems, chronic bone and joint disease.
Adverse reactions Diarrhea Pseudomembranous colitis caused by overgrowth of clastridium difficile
Miscellaneous Antibiotics p3
Contraindications and Precautions
Caution in patients with liver disease
Caution with patients with myasthenia Gravis due to neuromuscular
properties. Nephrotoxic, neurotoxic, neuromuscular blocking properties — use with
caution in concurrent use of similar acting drugs
Nursing considerations
IM may be painful
Teach patient to report diarrhea
Purine Nucleoside Group
Converts viral enzyme and terminates DNA chain of virus Only effective against actively replicating viruses.
Topical — Minimal percutaeous absorption Poorly absorbed p.o. Extensive distribution Minimally metabolized in the liver Excreted unchanged by the kidneys Half life: 2.5 hours
Purine Nucleoside Group p2
Herpes simplex, genitalis, and zoster. CMV, RSV, Influenza A
Adverse reactions
Well tolerated. Common effects are GI upset, lightheadedness and HA.
Contraindications and Precautions
Caution in pregnancy and breast feeding
Caution with renal disease and preexisting neurologic disorder
Nursing considerations
Monitor regime for other nephrotoxic drugs
Examine for active lesions (drugs not effect bacterial lesions)
Drug is expensive
Give with a full glass of water at regular intervals
Pyrimidine Nucleoside Group
Incorporates into viral DNA and stops building process Active against HIV, Ebstein Barr, and Hep B.
Rapidly absorbed p.o.
1 hour half life. Crosses blood brain barrier. Rapidly metabolized in the liver Excreted inactive by the kidneys
Pyrimidine Nucleoside Group p2
Treating HIV in children and adults
Preventing transmission to fetus in HIV pregnant women
Guidelines for starting therapy are controversial and constantly changing.
Adverse reactions
Anemia, granulocytopenia, and thrombocytopenia.(bone marrow
depression) GI upset
Myopathy including cardiomyopathy CNS — HA, seizures, somnolence, parasthesias, .agitation, insomnia
Pyrimidine Nucleoside Group p3
Contraindications and precautions
Contraindicated during the first 14 weeks of pregnancy
Contraindicated in neonates up to 3 months
Caution in patients with preexisting bone marrow depression, folic acid
and vit B12 deficiencies. Caution in patients with renal or hepatic disease Mothers with HIV are encouraged not to breast feed
Nursing considerations
Assess for hypersensitivity, pregnancy, hepatic and renal disease.
Assess for other drugs that are myelosuppressive
Monitor lab results
Teach that patient on this drug can still transmit HIV
Take 1 hour before meals and avoid fatty foods
Antitubercular Primary Drugs (First line Drugs)
Isoniazid, Rifampin, ethanbutol, pyrazinamide, and streptomycin are first line
Bacteriocidal and bacteriostatic Disrupts the cell wall
P.O. or IM. Absorbed from GI tract rapidly
Distributed to all fluids and tissues and crosses blood brain barrier
Metabolized in liver to inactive state
75% excreted in urine. The rest is feces, saliva, and sputum
Antitubercular Primary Drugs (First line Drugs) p2
Treat or prevent TB and other mycobacterial infections Unlabeled use —severe tremors of multiple sclerosis
Adverse Reactions
Hepatitis, jaundice Peripheral neuropathy
Contraindications and Precautions
Interacts with antiseizure drugs, alcohol, aluminum based antacids, benzodiazepines, ketoconazole, meperidine, anti coagulants. Contraindicated with acute hepatic disease Caution with alcoholics Caution with diabetics and those with seizure disorders
Antitubercular Primary Drugs (First line Drugs) p3
Nursing considerations
Given for 6 to 12 months
Assess for hepatic disease and alcoholism, DM and seizure disorders Teach to refrain from foods rich in tyramine: Cheese, dairy products, beef or chicken liver, beer and ale, red wine, avocados, bananas, figs, raisins, caffeine, and chocolate.
Secondary Drugs (Second line drugs)
Less effective and more toxic than first line drugs
PAS — Similar to sulfonamides -inhibits synthesis of folic acid Cycloserine— bacteriostatic, inhibits cell wall synthesis Kanamycin — aminoglycoside
PAS — p.o., Well absorbed, distributed to body tissues and fluids, metabolix=zed
in the liver and excreted in urine as inactive form. Cycloserine — p.o.. Same as PAS Kanamycin — IM or IV. See aminoglycosides
Treat TB
Secondary Drugs (Second line drugs) p2
Adverse Reactions
PAS — GI disturbances. Poorly tolerated by adults
Cyclserine — anxiety, depression, confusion, seizures, peripheral
neuropathy, hepatotoxicity Kanamycin — See aminoglycosides
Contraindications and Precautions
PAS used primarily as a substitute for ethambutol in pediatric patients
Nursing considerations
PAS tablets loose effectiveness if exposed to sunlight, extreme heat, or moisture. Advise patients not to store in kitchen or bathroom. Pyrodoxine may prevent neurotoxic effects of cycloserine
Inhibits protein synthesis
P.O., Absorbed readily. Widely distributed. Metabolized in lever. Excreted in urine bile and feces.
Used for prevention and spread of mycobacterium avium complex (MAC)
in HIV patients
Used for treating active MAC
Other p2
Adverse Reactions
Well tolerated
Rash, GI disturbances, neutropenia
Contraindications and Precautions
Liver enzyme inducer — decreases blood levels of other drugs
Nursing considerations
Imparts a harmless brown orange discoloration to urine, saliva and tears. Soft contact lenses may be permanently stained Teach patient about decreased blood levels of other drugs; i.e. oral contraceptives
Antifungal Polyenes
Contraindications and Precautions
Do not administer with other nephrotoxic drugs. Monitor electrolytes closely
Nursing Considerations
Complete a baseline assessment of renal and cardiac condition
Keep well hydrated
Administer test dose to determine hypersensitivy
Extra blankets, diversion therapy, warm fluids
Administer pre-treatment drgs as ordered; such as hydrocortisone,
meperidine, and ibuprofen. Use cental line if possible with in-line filter Accurate I & O. VS q 15 min during first dose.
Antifungal Polyenes p2
Anti fungal agent used to treat progressive and potentially fatal systemic fungal or protozoal infection.
Adverse Reactions
Infusion reactions: ha, chills, fever, rigors, hypotension, bronchospasm,
Electrolyte imbalances, anemia, leukopenia, thrombocytopenia. Ventricular fibrillation, seizures, cardiac arrest
Azole Antifungal drugs
Alters fungal cell membrane to cause leakage and death
Pharmacokinetics Oral and IV Rapid Gl absorption Widely distributed to tissues and fluids Elimination is renal; 60-80% excreted in urine unchanged
Wide spectrum antifungal activity
Drug of choice for oralpharangeal, esophalgeal, and vulvovaginal
Fungal prophylaxis for immunocornpromised patients Alternative to amphotericin
Azole Antifungal drugs p1
Adverse reactions
Diarrhea N/V abd pain, headache and dizziness
Contraindications and precautions
Drug interactions with anticoagulants, hydantoins, refampin, tolbutamide, cyclosporin, oral contraceptives, non-sedating antihistamines, hydrochlorthyiazide, theophylline, and zidvoudine.
Nursing Considerations
Assess for preexisting renal, hepatic disease or anemia
Absorption not affected by food
No alcohol
Refrain form acetominophen
Antiemetic or antidiarrheal can be given along with drug treatment
Monitor I & O
Similar to Amphotericin B
Available in topical, vaginal and oral forms
Not used for systemic infections
Pharmacokinetics Local effect
Nystatin p2
Candidasis of oropharyngel, cutaneous, mucocutaneous, and vulvovaginal
Orally used to treat GI fungus
"Swish and swallow" or "Swish and spit"
Adverse reactions
Mild transient N/V, diarrhea, and abdominal pain
Vaginal irritation
Contraindications and Precautions
Some forms contain sucrose which can cause hyperglycemia in diabetics
Nursing considerations
Teach swish and swallow technique
Teach about troche use —to allow troche to dissolve, do not chew or swallow
Antimalarial Chloroquine (Quinine)
Interrupts synthesis of RNA and DNA
Absorbed rapidly in GI system
Concentrates in erythrocytes, liver, spleen, kidney, lung, melinan-containing
tissue, and leukocytes. Penetrates CNS Half life 70-120 hours. Excreted unchanged in kidney and feces
Antimalarial Chloroquine (Quinine) p2
Prophylaxis and treatment of malaria, extra-intestinal amebiasis, rheumatoid arthritis, and discoid lupus, erythematosus.
Adverse reactions
Hypotension, cardiac changes, GI upset Potential hearing and visual problems
Contraindications and Precautions Hypersensitivity
Preexisting hearing or visual loss Caution with psoriasis Caution with alcoholics
Caution in patients with GI disorders, blood dyscrasias, dental disease, and .neurologic disorders
Nursing considerations
Baseline assessment of vision, hearing, neurological disorers, liver and
kidney disease.
Assess for blood dyscrasias and skin disorders. Prophylaxis 2 weeks prior to going to an area with endemic malaria and
continue for two weeks after. If dosing is weekly, take on same day each week Take with food to decrease Gl upset Take acetaminophen to decrease HA Avoid alcohol
Antiprotozoal Antiinfective
Acts against anaerobic bacteria by inhibiting DNA synthesis
Oral, IV, or topical
Distributed to tissue and fluids including CSF.
Metabolized in the liver
Adverse reactions
N/V, dry mouth, altered sense of taste, anorexia, and abdominal pain.
Contraindications and Precautions
Disulfiram reaction in alcoholics
Caution in patients with bone marrow depression
Caution with hepatic dysfunction
Antiprotozoal Antiinfective p2
Nursing considerations
No alcohol including OTC drugs that contain alcohol
Sexual partner also needs to be treated for trichomonas.
Discolored urine not harmful
Administer with food to decrease GI upset
Monitor for thrombophlebitis and CHF, oral candiasis and vaginal
Monitor for peripheral neuropathy If treated for giardiasis , three clear stool specimens several days apart
will determine success of therapy.
Antihelmintic Mebendazole (Prototype
Selectively damages cytoplasmic microtubules in the absorptive and intestinal tract of the helminth but not the host.
Minimally absorbed by the GI tract Most is excreted in the feces
Adverse reaction
Rare due to poor absorption
Antihelmintic Mebendazole (Prototype p2
Contraindications and Precautions Hypersensitivity
Caution with inflammatory bowel disease and hepatic disease Interacts with anticonvulsant drugs to decrease effect of Mebendazole
Nursing considerations
Collect stool specimens to ensure drug is therapeutic
Monitor patient's contacts —helminthic infections are highly contagious
Entire family may be treated
Disinfect clothing and bedding
Increase fluid intake

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