Anti-Infectives UNIT II ( Ch 7)

NURSING PROCESS: EVALUATION

- therapeutic response is achieved, no evidence of infection -adverse reactions are identified, and reported; managed successfully with the appropriate nursng interventions skin intact and free of infection maintains adequate gas exchange adequate fluid intake for proper urinary elimination reports adequate bowl movements mucous membranes are moist and intact reports comfort w/o fever pt/fam express confidence and demonstrate understanding of drug regimen.

ADVERSE REACTIONS

-Glossitis (inflammation of tongue) when given orally -Stomatitis (inflammation of mouth), dry mouth -Gastritis -Nausea, vomiting -Diarrhea, abdominal pain -pain @ injection site when given IM -irritation of vein and phlebitis (inflammation of a vein) when given IV

NURSING PROCESS: ONGOING ASSESSMENT

-monitor temp -relief of sx -increased appetite -change in appearance -amount of drainage additional C&S tests may be performed during therapy bc microorganisms causing the infection may become resistant to the antibiotic, or a superinfection may occur. Check lab reports within 3-7 days of the initial treatment, verify that the infection being treated is susceptible to the drug given, notify PCP. check the patients skin regularly for rash and be alert for any lose stools or diarrhea. a urinalysis, CBC, and renal/hepatic function tests also may be performed at intervals during drug therapy

INTERACTIONS

1) Aminoglycosides - Anti-Infective effect: Increased risk for nephrotoxicity 2) Oral anticoagulants- Blood thinner effect: increased risk for bleeding 3) Loop diuretics- hypertension, reduce edema effect: increased cephalosporin blood level Probenecid (Benemid, used for gout pain) will increase the levels of most cephalosporins (EXCEPT cefoperazone, ceftazidime, and ceftriazxone)

DRUG CLASSES

1) Penicillins -Natural penicillins -Aminopenicillins -Extended Spectrum penicillins 2)Cephalosporins -1st gen -2nd gen -3rd gen -4th gen -5th gen 3)Carbapenems

KEY POINTS

1) penicillin, cephalosporins, carbapenems, and vancomycin-type drugs are primarily bactericidal; they work by breaking or inhibiting the growth of the cell walls found in bacterial cells. Categories of penicillin drugs are identified by modifications for resistance, and cephalosporin generations tend to define the sensitivity of the drugs to microorganisms. 2)these drugs are used to treat bacterial infections such as UTIs or otitis media, or prophylactically to prevent secondary bacterial infections. 3)people allergic to penicillin may be allergic to cephalosporins bc they are structurally and chemically related drugs 4)bacteria can become resistant to certain drugs. drugs with modifications are created to combat resistance, one if the best methods to prevent resistance is to teach the patient to take medication as instructed: take on time, no omissions, and for the length of the prescription 5)adverse reactions are often times GI, and superinfections can occur when normal flora is killed by the drugs. chronic use of cephalosporins may result in damage to the kidneys. older pts using these drugs should be monitored closely for kidney function.

ACTIONS

4 GROUPS OF PENICILLIN: -Natural Penicillin -Penicillinase-resistant penicillins -aminopenicillins -extended-spectrum penicillins ALL of which work to inhibit( slow down) the integrity of the bacterial cell wall. NATURAL PENICILLINS: fairly narrow spectrum of activity, meaning they are effective against only a FEW strains of bacteria. Newer chemically modified aminopenicillins were developed to combat this problem. bc of their chemical modifications they are more slowly excreted by the kidneys an thus have a somewhat wider spectrum of antibacterial activity. Bacterial resistance: example- ability of certain bacteria to produce penicillinase, an enzyme that inactivates penicillin. the penicillinase-resistant penicillins were developed to combat this problem. certain bacteria have developed the ability to produce enzymes called beta-lactamases, which are able to destroy the beta-lactum ring of the drug. Fortunately, chemicals were discovered that inhibit (stop) the activity of theses enzymes. Penicillin-beta-lactamase inhibitor combinations are a type of penicillin with a wider spectrum of antibacterial activity ***examples of these beta-lactamase inhibitors are clavulanic acid, sulbactam, tazobactam. when these chemicals are used alone, they have little antimicrobial activity. However, when combine with certain penicillins, they extend the spectrum of the penicillins antibacterial activity. the beta-lactamase inhibitors bind with the penicillins and protect the penicillin from destruction. PENICILLIN-BETA-LACTAMSE INHIBITORS COMBOS. - Augmentin - combo of amoxicillin & clavulanic acid Unasyn- combo of ampicillin and sulbactam Zosyn- combo of piperacillin & tazobactam Timentin- combo of ticarcillin and clavulante EXTENDED SPECTRUM PENECILLINS effective against an even wider range of bacteria than the broad-spectrum penicillins. these are used to destroy bacteria such as Pseudomonas.

CHAPTER 7

Antibacterial Drugs that Disrupt the Bacterial Cell Wall

CONTRAINDICATIONS AND PRECAUTIONS

CONTRAINDICATED IN PATIENTS WITH: -hx of hypersensitivity of penicillin/cephalosporins should be used cautiously in patients w/: -renal disease -asthma -bleeding disorders -GI disease -pregnancy (preg cat. C) -lactation (may cause diarrhea or candidiasis in the infant) -hx of allergy any indication of hypersensitivity is reason for caution

CONTRAINDICATIONS AND PRECAUTIONS

DO NOT ADMINISTER cephalosporins if the pt has a hx of allergies to cephalosporins. should be used cautiously in pts with -renal disease -hepatic impairment -bleeding disorders -pregnancy (Cat. B) -known penicillin allergy

NURSING PROCESS: IMPLEMENTATION cont.

EDUCATING THE PATIENT AND FAMILY -Prophylaxis: take as prescribed until the PHCP discontinues -Infection: complete FULL course of therapy. do NOT stop even if sx subside, unless directed to do so by PHCP -take the drug @ prescribed time of day- important to keep adequate amounts of the drug in the body throughout the entire 24 hours of each day -Penicillin (ORAL) take on empty stomach; 1 hr a.c or 2 hr p.c (EXCEPTIONS Penicillin V, amoxicillin) -take each dose with a full 8 oz glass of water -oral suspensions: keep refrigerated (if indicated), shake well before using ( if indicated) return to fridge immediately after use. drugs that require refrigeration lose their potency when kept out in room temp. a small amount of the drug may remain after treatment course, DISCARD- loses potency after a few weeks. -avoid drinking alcoholic beverages when taking the cephalosporins and for 3 days after completing the course of therapy, bc severe reactions may occur. -to reduce superinfection risk take yogurt, buttermilk, acidophillus caps. -if you are a woman prescribed ampicillin or penicillin V and who takes OCPs containing estrogen, use additional contraceptive measures. -notify PHCP immediately regarding: skin rash, urticaria, severe diarrhea, vaginal or anal itching, black or furry tongue, sores in mouth, swelling around mouth/eyes, difficulty breathing, GI disturbances- N/V/D. do NOT give next dose until consult with PHCP -NEVER give this drug to another individual even though their sx may be the same as yours.

Steven-Johnson syndrome

FEVER, COUGH, MUSCULAR ACHES/PAINS, LESIONS OF THE SKIN, MUCOUS MEMBRANES, AND EYES; the lesions appear as RED WHEALS OR BLISTERS, often starting on the face, in the mouth, or on the lips, neck and extremities.

ADVERSE REACTIONS

GI SYSTEM REACTIONS : -N/V/D OTHER REACTIONS -headache -dizziness -Malaise -heartburn -fever -nephrotoxicity -((((((hypersensitivity may occur with administration that may range from mild-life threatening. MILD hypersensitivity reactions include -pruritis -urticaria (hives) -skin rash SERIOUS REACTIONS -SJS -hepatic dysfunction -renal dysfunction)))))))) -aplastic anemia (deficient /rbc production) -Toxic Epidermal necrolysis (death of the epidermal layer of the skin) ADMINISTRATION ROUTE REACTIONS: -pain -tenderness -inflammation @ injection site when given IM -phlebitis or thrombophlebitis along the vein when given IV therapy with cephalosporins may result in bacterial or fungal superinfection. diarrhea may be an indication of pseudomembranous colitis, which is one type of bacterial superinfection.

HERBAL CONSIDERATIONS

Goldenseal (Hydrastis canadensis) has been used to wash inflamed or infected eyes and in making yellow dyes. more traditional uses: antiseptic for the skin, mouth wash for canker sores, treatment of sinus infections and digestive problems such as peptic ulcers and gastritis. 19th century- "herbal antibiotic" for treating gonorrhea and UTIs. used over time by american indian tribes as -insect repellent -stimulant -diuretic there is NO scientific evidence that supports this. more myths: -masks the presence of illicit drugs in the urine EVIDENCED BASED -treatment for diarrhea caused by bacteria or intestinal parasites, such as Giardia. CONTRAINDICATIONS -in pregnancy in pts with hypertension adverse reactions are rare, when used as directed. however should NOT be taken for more than 1 wk.

NURSING ALERT

IVPB administer each IV dose of vancomycin or telavancin OVER 60 MINUTES (ortivancin is infused in 3 HOURS/180 MINUTES) Too rapid administration may result in sudden and profound fall in BP and shock when giving vancomycin, telavancin, or ortivancin IV, closely monitor the infusion rate and the patients BP REPORT: -decrease in BP -occurrence of throbbing neck or back pain these sx could indicate a SEVERE adverse reaction referred to as RED NECK SYNDROME or RED NECK. OTHER SX: -fever -chills -parasthesia (refers to a burning or prickling sensation that is usually felt in the hands, arms, legs, or feet, but can also occur in other parts of the body.)) -erythema (redness of neck and back)

NURSING DIAGNOSES

Impaired Skin Integrity: r/t to hypersensitivity to the drug Risk for Impaired Gas Exchange: r/t allergic reaction to drug Impaired urinary elimination: r/t nephrotoxic effects of cephalosporins Diarrhea r/t bacterial secondary infection or superinfection Impaired oral mucous membranes r/t a secondary bacterial or fungal infection Impaired comfort:Increased fever: r/t ineffectiveness of antibiotics against the infection

NURSING PROCESS: IMPLEMENTAITION cont.

MONITORING AND MANAGING PATIENT NEDEDS: Impaired Skin Integrity: treatment of minor hypersensitivity reactions may include administration of an antihistamine such as diphenhydramine (Benadryl) for a rash or itching. in mild cases, or where the benefit of the drug outweighs the discomfort of skin lesions, administer frequent skin care. Emollients , antipyretic creams, or a topical corticosteroid may be prescribed to promote comfort. INSTRUCT -avoid rubbing area -non-irritating clothing REPORT : -rash -hives may be a precursor to SEVERE anaphylactic reaction. ________________________________________________________________ RISK FOR IMPAIRED GAS EXCHANGE major hypersensitivity reactions such as: -bronchospasm -laryngospasm -hypotension -angioedema require IMMEDIATE treatment with drugs such as epinephrine, cortisone, or an IV anti-histamine. when respiratory difficulty occurs, tracheostomy may need to be performed. _______________________________________________________________ IMPAIRED UNRINE ELIMINATION nephrotoxicity may occur with the administration of cephalosporins. early sign of adverse reaction may be a decrease in urine output. ** measure and record I&Os and notify PHCP if the output is <500 ml daily. ________________________________________________________________ Diarrhea indication of superinfection of the GI tract or pseudomembranous colitis. -inspect all stools and report diarrhea. if diarrhea occurs and there is blood in stool, it is important to save a sample of the stool, which should be sent to the lab to rule out C.diff. You should also collect a sample for occult blood using a test on the nursing such as Hemoccult. observe for other s/s of bacterial infection in vaginal or anal area -pain -itching severe superinfection s/s may need additional measures such as antipyretics for fever or antifungal drugs _____________________________________________________________ IMPAIRED ORAL MUCOUS MEMBRANES oral penicillin administration may cause fungal superinfection in the oral cavity. characterized by: -varying degrees of of oral mucous membrane inflammation -swollen/red tongue -swollen gums -pain in mouth/throat inspect patients mouth DAILY for evidence of: -glossitis -sore tongue -ulceration -black,furry tongue explain that if diet permits: -yogurt -buttermilk -Acidophillus caps may be taken to reduce the risk of superinfection. inspect the mouth and gums often and give frequent mouth care with a non-irritating solution. a soft-bristled toothbrush is used when brushing is needed. A non-irritating soft diet may be required. monitor dietary intake to ensure adequate nutrition. antifungals or local anesthetics are sometimes are recommended to soother the irritated membranes. ______________________________________________________________________ IMPAIRED COMFORT: INCREASED FEVER increase in temp several days after start of therapy may indicate secondary bacterial infection or failure of the drug prescribed to control the original infection. TAKE VITALS q4hrs, or more often if necessary. on occasion fever may be cause to adverse reactions to the penicillin, which in case can be treated with antipyretics.

ADVERSE REACTIONS

MOST COMMON W/ these drugs -nausea -vomiting -diarrhea -rash RISK OF: -pseudomembranous colitis ASSESS STOOLS FOR BLOOD WHEN THE PATIENT HAS DIARRHEA. carbapenems also can cause : -abscess @ inj.site -phlebitis @ inj. site an abscess is suspected if the injection site appears: -red -tender -warm to touch Note: tissue sloughing (peeling) @ the injection site may also occur. Nephrotoxicity (kidney damage) and ototoxicity (damage to organs of hearing) may be seen with the administration of vancomycin especially in pts with pre-existing kidney disease. ADDITIONAL ADVERSE REACTIONS: -chills -fever -urticaria -sudden fall of BP with parenteral administration

USES

Meropenem (Merrem IV)- intra-abdominal infections and bacterial meningitis. Imipenem-cilastatin (Primaxin)- treats serious infections, endocarditis, & septicemia. Doripenem (Doribax) is used to treat intra-abdominal and complicated UTIs caused by bacteria. Telavancin (Vibativ) and oritavancin (Orbactiv)- treat complicated skin infections and skin structure infections bc they are effective against many strains of Staph and Strep infections including methicillin-resistant organisms. Vancomycin (Vancocin) is used in the treatment of serious gram-positive infections that do NOT respond to treatment with other anti-infectives. may also be used to treat anti-infective-associated pseudomembranous colitis caused by C.diff. the Monobactams have bactericidal action and are used to treat gram-negative microorganisms.

NURSING PROCESS: ASSESSMENT

OBTAIN: -health hx -past medical/surg treatment -drug hx -current infection sx -DRUG ALLERGIES (make sure they are not allergic to penicillin/cephalosporins) -vitals -obtain s/s of infection (color, drainage, pain, redness, inflammation, color of sputum, odor.) -assess infected area -general apperance a C&S test is almost ALWAYS ordered. liver and kidney function tests may be ordered by the PHCP, if so check those results before administering the drug.

INTERACTIONS

Oral Contraceptives w/estrogen effect: decreased effectiveness of contraception with ampicillin, penicillin V Tetracyclines: Anti-Infective effect: decreased effectiveness of penicillins Anticoagulants- prevent blood clots effect: increased bleeding risks (w/ large doses of penicillin) Beta-adrenergic blocking drugs- BP control and heart problems effect: may increase the risk for anaphylactic shock

NURSING PROCESS:IMPLEMENTATION

PROMOTING OPTIMAL RESPONSE TO THERAPY: PROPER ADMINISTRATION: results of C&S tests may take days, however an infection is treated ASAP. Provider determines treatment of choice until results of C&S return. usually, a broad-spectrum anti-biotic for initial treatment is used bc of the many penicillin-resistant strains of microorganisms. __________________________________________________________________ ORAL ADMINISTRATION adequate blood levels MUST be maintained for the drug to be effective. Accidental omission or delay of the dose results in decreased blood levels, which will reduce the effectiveness of the drug. best to give oral penicillins on empty stomach-- 1 hour a.c or 2 hours p.c Penicillin V and amoxicillin may be given WITHOUT regard to meals. cephalosporins: most may be taken on an empty stomach, especially ceftibuten (Cedax) however if GI disturbances occur administer with food. the absorption of oral cefuroxime and cefpodoxime is increased when given with food powders- reconstituted by pharmacist or nurse SHAKE oral suspensions well before administration , refrigerate until used. _________________________________________________________________ PARENTERAL ADMINISTRATION in most facilities the drug is prepared in the pharmacy and delivered by the nurse. However, when service is not available nurse prepares based of manufacturers label. -reconstitution of powder for inj. -storage of unused portions -drug life after reconstituted -methods of IV admin. -precautions

Identifying the Appropriate Anti-Infective

RESISTANCE TO DRUGS bacterial resistance- ability of bacteria to produce substances that inactivate or destroy the antibiotic. bc bacteria have this ability, many more drugs have been developed in addition to the sulfonamides and penicillins to fight bacterial infections. they include, cephalosporins, the tetracycline group, and various other drugs. some bacteria may be naturally resistant to an antibiotic, or they may acquire a resistance to the drug. when the susceptible bacteria are destroyed, what remains are the the resistant bacteria. As a result, strains of drug-resistant bacteria multiply. these can range from the penicillinase enzyme producing bacteria to methicillin-resistant staphylococcus aureus (MRSA) MRSA is a type of bacteria that is resistant to certain antibiotics including: -methicillin -oxacillin -penicillin -amoxicillin MRSA occurs more frequently in those in hospitals/healthcare facilities ( skilled nursing facilities and dialysis centers ) and who have weakened immune systems. also emerging is a new resistance associated with bacteria that have both natural and acquired resistance. EXAMPLE- Vancomycin-resistant enterococci (VRE). this drug resistance is affecting severely ill, immunocompromised patients in intensive care, transplant, and some cancer treatment units. 10 COMMANDMENTS OF ANTIBIOTIC USE: 1) teach pt nondrug ways to manage nonbacterial infections 2)know the bacteria, treat it specifically 3)treat for effectiveness and shorten the course, if appropriate 4)communicate with pts to increase adherance 5)use a combo of drugs only in specific situations 6)substitute only when equivalent product is available 7)educate to prevent self-prescription 8)follow evidenced-based guidelines 9)use lab results correctly to prescribe 10)research and understand your local trends and limits

HYPERSENSITIVITY (allergic) REACTIONS

S/S -skin rash -Urticaria (hives) -sneezing -Wheezing -Pruritis (itching) -Bronchospasm (spasm of the bronchi) -Laryngospasm (spasm of the larynx) -Angioedema (also angioneurotic edema) swelling of the skin & mucous membranes, especialy around the mouth and throat -hypotension- can progress to shock -s/s resembling serum sickness- chills, fever, edema, joint and muscle pain, malaise anaphylactic reactions occur more frequently after parenteral administration, but can also happen with oral use. S/S of anaphylactic reaction: -severe hypotension -loss of consciousness -acute respiratory distress if not treated immediately, death can occur. once a person is allergic to one penicillin, they are usually allergic to all of the penicillins. **those allergic to penicillin also have a higher incidence of allergy to the cephalosporins. allergy to drugs in the same or related groups is called cross-sensitivity. For example, a person allergic to penicillin may also be sensitive to cephalosporins. OTHER REACTIONS: more severe reactions associated with penicillin include hematopoietic (blood cell changes): -Anemia (low blood cell count) -Thrombocytopenia (low platelet count) -Leukopenia (low WBC count) -Bone marrow depression

Identifying the Appropriate Anti-Infective

SELECTION OF DRUGS: Culture and Sensitivity- identifying which antibiotic will kill a specific type of microorganism. Antibiotics are selected based of which microorganism is sensitive to the antibiotic. When the microorganism is sensitive to a specific antibiotic that will be the drug that is effective in the treatment of the present infection. drugs are BACTERICIDAL ("suicidal" - kills/destroys) when there is adequate concentrations of the drug in the body. The concentration of any drug in the body is referred to as the blood level. an inadequate concentration (inadequate blood level) of an antibiotic may produce bacteriostatic activity ((slowing/retardation the multiplication of bacteria)), which may not control the infection.

pseudomembranous colitis

SEVERE, LIFE-THREATENING form of diarrhea that occurs when normal flora of the bowel is eliminated and replaced with Clostridium difficile (C.diff) bacteria

NURSING PROCESS: PLANNING

_______________ pg 78

NURSING ALERT

a disulfiram-like (Antabuse) reaction may occur if alcohol is consumed within 72 hours after administration of certain cephalosporins (i.e., cefamandole, cefoperazone, and cefotetan) Sx of a disulfiram-like reaction (associated with the use of disulfiram, a drug used to treat alcoholism) include flushing, throbbing in the head and neck, respiratory difficulty, vomiting, sweating, chest pain, and hypotension SEVERE reactions may cause dysrhythmias and unconsciousness.

NURSING ALERT

after administration of penecillin IM the outpatient setting, ask the patient to wait in the area for at least 30 minutes. Anaphylactic reactions are most likely to occur within 30 minutes after injection

cross-sensitivity

allergy to drugs in the same or related groups

methicillin- resistant Staphylococcus aureus ( MRSA)

bacterium that is resistant to methicillin

Prophylaxis

bc penicillins targets bacterial cells, it is of NO value in treating viral or fungal infections! can be prescribed for prophylaxis against a potential secondary bacterial infection that can occur in a patient with a viral infection. in these situations, the viral infection has weakened the body's defenses and the person is susceptible to other infections, particularly bacterial infection. have been historically prescribed as prophylaxis for a potential infection in high-risk individuals undergoing a procedure that will break the skin defense system, such as those with Hx of rheumatic fever. - in this case it is take several hours or sometimes days before and after an operative procedure (dental, oral, or upper respiratory tract procedure) that can result in bacteria entering the bloodstream. penicillin also may be given prophylactically on a continuing basis to those with rheumatic fever or chronic ear infections.

NURSING ALERT

be sure to question the patient about allergy to penicillin or cephalosporins before administering a dose, even when accurate drug hx was obtained @ time of assessment (these allergies may have been forgotten @ time of original assessment)

ACTIONS

carbapenems inhibit synthesis of the bacterial cell wall and cause the death of susceptible cells. Vancomycin and its synthetic derivative drug (telavancin) and the drug (Orbactiv) all act against susceptible gram-positive bacteria inhibiting bacterial cell wall synthesis and increasing cell wall permeability. Aztreonam has a beta-lactam nucleus and therefore is called monobactam. This is structurally different from the beta-lactam ring of the penecillins, yet it still functions to inhibit bacterial cell wall synthesis.

CONTRAINDICATIONS, PRECAUTIONS, & INTERACTIONS

carbapenems, aztreonam, and televancin are contraindicated in patients w/ : -allergic to cephalosporins and penecillins -pts with renal failure NOT RECOMMENDED FOR -children < 3 months -during pregnancy (CAT. B) -lactation carbapenems are used cautiously in patients with -CNS system disorders -seizure disorders -renal failure -hepatic failure ** The excretion of carbapenems is inhibited when the drug is administered to a patient also taking probenecid (Benemid) ((extends effectiveness by delaying excretion from kidneys)) Aztreonam should be used cautiously in patients with renal or hepatic impairment vancomycin should NOT be used in pts with : -hypersensitivity to the drug used cautiously in pts: -with renal/hepatic impairment -pregnancy ( CAT C) -lactation when administered with ototoxic and nephrotoxic drugs, additive effects may occur. these drugs should be used with caution in patients undergoing: -anticoagulant therapy bc or increased risk for bleeding.

ACTIONS

cephalosporins have a beta-lactum ring and target the bacterial cell wall, making it defective and unstable, ultimately killing thew bacteria. usually bactericidal( "suicidal" kill/destroy bacteria)

synthesis

combining or growing a number of different parts to make a new item.

culture and sensitivity test

culture of bacteria to determine to which antibiotic the microorganism is sensitive

nephrotoxicity

damage to kidneys by a toxic substance

malaise

discomfort, uneasiness

pathogens

disease-producing microorganisms

CEPHALASPORINS

divided into 5 generations. progression from the 1st - 4th generation drugs shows an increase in sensitivity of gram negative microorganisms and a decrease in gram positive micro organisms. 4th gen- has a broader spectrum and longer direction of resistance to beta-lactamase used to treat UTIs and skin infections and hospital acquired pneumonias. 5th gen- are effective against MRSA and other resistant bacteria. EXAMPLES 1st gen: cephalexin (Keflex), cefazolin (Ancef) 2nd gen: cefaclor (Raniclor), cefoxitin (Mefoxin), cefuroxime (Zinacef) 3rd gen: cefoperazone (Cefobid), cefotaxime (Claforan), ceftriaxone (Rocephin) 4th gen: cefepime (Maxipime) 5th gen: ceftaroline (Teflaro)

penicillinase

enzyme produced by bacteria that deactivates penicillin

otitis media

infection in the middle ear

stomatitis

inflammation of a cavity opening, such as the oral cavity.

phlebitis

inflammation of a vein

thrombophlebitis

inflammation of a vein WITH clot formation

glossitis

inflammation of the tongue

NURSING ALERT

is the reaction really an allergy? approx 30 million ppl report having a drug allergy to penicillin. is the reaction really a TRUE allergy response or did the person experience a nonallergy reaction such as contact dermatitis? research shows that about 95% of those who say they are allergic, are actually not. This causes an increase in health care costs when more expensive drugs are used to treat a response which is not really an allergy and which can create longer hospital stays.

angioedema

localized WHEALS or SWELLINGS in subcutaneous tissue or mucous membranes, which may be causes by an allergic response.

USES

natural and synthetic penicillins are uses in the treatment of moderate - mildly severe bacterial infections such as: -UTIs -Septicemia (life threatening complications of an infection) -Meningitis -Intra-abdominal infections -Sexually Transmitted Infections (syphilis) -Pneumonia and other respiratory infections bacteria that may respond to penicillin therapy: -pneumococci -group A beta-hemolytic streptococci because of the increasing resistance of staphylococci to penicillin G, ,the penicillinase-resistant penicillins are used as initial therapy for any suspected staphylococcal infection until C&S results are known.

NURSING ALERT

observe pt closely for hypersensitivity reactions, which may occur @ ANY time during treatment with the penicillins. if it does occur, contact PCP immediately and withhold drug.

LIFESPAN CONSIDERATIONL GERONTOLOGY

older adults are more susceptible to nephrotoxicity caused by cephalosporins. especially if there is already renal impairment. if renal impairment is present- lower dosages and monitoring of blood creatinine levels are indicated. **blood creatinine levels >4 mg/dL indicate serious renal impairment. In older patients with decreased renal function, a dosage adjustment may be necessary.

perioperative

pertaining to the preoperative, intraoperative, or postoperative period

bacterial resistance

phenomenon by which a bacteria-produced substance INACTIVATES or DESTROYS an antibiotic drug

beta-lactam ring

portion of the penicillin drug molecule that can break a bacterial cell wall

CHRONIC CARE CONSIDERATIONS: PKU

ppl with (PKU) phenylketonuria need to be aware that the oral suspension of cefprozil (Cefzil) contains phenylalanine, a substance that ppl with PKU cannot process. In addition , diabetic patients who use urine testing for determining diabetic medicine dosing and who are prescribed cephalosporins need to be aware that this drug may interfere with accurate tests results. the PCP should be consulted before the drug and diet changes are made

prophylaxis

prevention

CARBAPENEMS & MISC. DRUGS THAT INHIBIT CELL WALL SYNTHESIS

the carbapenems, vancomycin, and monobactam drugs all play a role in the inhibition of bacterial cell wall synthesis.

Intro

the drug classes are effective bc they target the cell wall. penicillins, cephalosporins, carbapenems, and Vancomycin ALL inhibit (slow down) bacterial cell wall synthesis (growth and repair). when the drug breaks down the cell wall the bacteria die. enzymes known as penicillin-binding proteins (PBPs) are involve in bacterial cell wall synthesis and cell wall division. Antibiotics, which interfere with these processes, inhibit cell wall synthesis, causing rapid destruction of the bacterial cell. Penecillins: when first used these drugs worked very well bc bacteria have a receptor on the cell wall that attracts the penicillin molecule. that is, when the drug attaches to the cell , a portion of the drug molecule (beta-lactum ring) breaks the cell wall wall and the cell dies (bactericidal action) penicillins after many years have now developed resistant strains of microorganisms, making the penicillins less effective than some of the new antibiotics in treating a broad range of infections Cephalosporins: more commonly used group. structurally and chemically related to penicillins. effective in the treatment of infections with almost all of the strains of bacteria that have become resistant to penicillin. Carbapenems: relatively new class of bactericidal drugs that have the largest spectrum of any antibiotic.

anaphylactic shock

unusual or exaggerated allergic reactions

USES

used in treatment of infections cause by bacteria: -respiratory infections -Otitis media (middle ear infection) -bone/joint infections -complicated interabdominal or GU tract infections used prophylactically to prevent infection when victims are treated following a sexual assault. infections Dx'ed post assault include: -trichomoniasis -bacterial vaginitis -gonorrhea -chlamydia PRIMARY DRUG IN POST SEXUAL ASSAULT medication protocols. class may also be used in perioperative period - (preop, intraop, postop) for infection prevention in pts having surgery on a contaminated or potentially contaminated area, such as the GI tract or the vagina.

LIFESPAN CONSIDERATIONS: GERONTOLOGY

when a penicillin or cephalosporin is given IM, inject the drug into a LARGE muscle mass, such as gluteus muscle or lateral aspect of the thigh. consider muscle atrophy for non-ambulatory patient. assess muscle before administering if this is the case. ROTATE injection sites. Warn the patient that the time the drug in injected into the muscle, there may be stinging or burning sensation and the area may be sore for a short time.

PATIENT TEACHING for IMPROVED OUTCOMES

when you teach make sure the pt understands: -reason drug is prescribed (name,dosing, regimen,frequency of admin.) have them repeat the reasonings to verify understanding. use interpreter for those with english proficiency. -stress importance of continued, uninterrupted therapy, even if they feel better after a few days or if sx resolve. -give take home material;use interpreter for those with english proficiency. -instruct to take till finished unless otherwise indicated by PCP -urge to discard once completed or discontinued -warn them NOT to use leftovers for another family member or as self treatment for superinfection -review all possible s/s of adverse reactions and s/s of new infections or worsening of infection, both verbally and in writing -instruct to notify PCP immediately if they experience any adverse reactions or s/s of infection. -notify the PCP if the sx of the infection do not improve or if the condition becomes worse -NEVER skip doses, or stop therapy unless otherwise indicated. when a penicillin is taken for too long for prophylaxis you may feel well despite the need for long-term antibiotic therapy. there may be a tendency to omit one or more doses or even neglect to take the drug for an extended time.