Chapter 10: Anti-Infectives: Antitubercular and Antifungal Drugs

ANS: A Breast enlargement in men (gynecomastia) is a common side effect of isoniazid. This physical change can be very distressing and embarrassing to men, and they should be reassured that the problem is temporary. Even though it is distressing, breast enlargement is not a reason to stop drug therapy.

A male patient who has been prescribed isoniazid (INH, Nydrazid) reports that his breasts have enlarged since starting therapy. What is your best response? a. "This is common with isoniazid and will disappear after you stop drug therapy." b. "Is the enlargement the same on both sides or is one breast larger than the other?" c. "If you are not having difficulty getting an erection, do not worry about this change." d. "I will report this problem to your prescriber and see if it is possible for you to stop taking this drug."

ANS: D This WBC count is lower than normal. Terbinafine and flucytosine (Ancobon) can further reduce this patient's WBC count and greatly increase his or her risk for infection.

A patient about to start systemic antifungal therapy has a white blood cell (WBC) count of 3200 cells/mm3. Which antifungal drug must be avoided for this patient? a. Fluconazole (Diflucan) b. Ketoconazole (Nizoral) c. Micafungin (Mycamine) d. Terbinafine (Lamisil)

ANS: A All of these values are abnormal; however, only the RBC count is seriously out of the normal range. One of the most serious adverse effects of rifampin (a major part of first-line drug therapy for TB) is suppression of RBC production, leading to anemia. This patient's RBC level is only about half of normal.

A patient has been prescribed all four first-line drugs for tuberculosis (TB). Which laboratory blood value is most important to report to the prescriber first? a. Red blood cells (RBCs) 2.2 million/mm3 b. International normalized ratio 1.6 c. White blood cells 6000/mm3 d. Sodium 134 mEq/L

ANS: C Want 420 mg/Have 60 mg in 1 mL. 420/60 = 7 mL.

A patient is prescribed 420 mg of rifampin to be added to 500 mL of dextrose 5% in water (D5W). The vial contains rifampin 60 mg/mL. How many milliliters should you add to the D5W for the correct? a. 0.16 mL b. 5mL c. 7mL d. 8mL

ANS: A 500 mL/6 = 83.3 mL/h. 83.3 mL/60 minutes = 1.38 mL/min. Round up to 1.4 mL/min.

A patient is prescribed 50 mg of amphotericin B (Fungizone) by intravenous infusion in 500 mL of dextrose 5% in water (D5W) over 6 hours. How many milliliters (mL) per minute should you set the pump to infuse? a. 1.4 mL b. 2.2 mL c. 4.2 mL d. 6.2 mL

ANS: D Rapid administration of IV amphotericin B is associated with more severe rigors, hyperkalemia, and a more rapid onset of renal insufficiency. It is recommended that the drug be administered over a 6-hour time period regardless of the dose.

A patient is prescribed amphotericin B (Fungizone) 400 mg intravenously. How fast should you infuse this drug? a. Immediately by intravenous (IV) push b. Over a period of 60 minutes c. Over a period of 2 hours d. Over a minimum of 6 hours

ANS: C Among its many adverse effects, amphotericin B is very irritating and causes phlebitis at the site of infusion. This can occur quickly, sometimes after only one drug dose. When it is present, the IV site needs to be changed to prevent more complications and patient's discomfort.

A patient is receiving IV amphotericin B (Fungizone) for a systemic fungal infection. Which assessment parameter should you perform to determine whether the patient is having an adverse reaction to the therapy? a. Measure abdominal girth for presence of ascites b. Assess mouth and oral cavity for candidiasis c. Assess infusion site for phlebitis d. Assess calves for pain

ANS: A, B, D, G Echinocandins can increase the rate of clot formation, which increases the risk for deep vein thrombosis (DVT). DVT is most likely to occur in the veins of the lower legs and in the pelvis. Symptoms of DVT in an extremity include swelling, warmth, and pain or discomfort. All the systemic antifungal agents can cause renal insufficiency. Anyone prescribed these drugs must have renal function monitored. Any intravenous antifungal drug can irritate veins and cause phlebitis. Skin irritation and rashes can occur with systemic antifungal therapy. Rashes may be severe with many types of lesions (Stevens-Johnson syndrome). If the rashes become widespread with crusting, fever, and tissue necrosis, the condition can be life-threatening. Echinocandins do not affect intestinal motility or capillary refill. They also do not directly affect bone marrow production of white blood cells.

A patient is receiving IV caspofungin (Cancidas). Which assessments are most important to perform daily? (select all that apply) a. Assessing both calves for swelling, redness, and pain b. Examining the skin for rash and blisters c. Assessing capillary refill in fingers and toes d. Assessing the injection site for irritation or phlebitis e. Reviewing laboratory reports of white blood cell counts f. Listening for bowel sounds in all four abdominal quadrants g. Reviewing laboratory reports for blood urea nitrogen (BUN) and creatinine

ANS: 30 120 mL/h is 2 mL/min (120 mL/60 minutes in 1 hour). 2 mL/min 15 gtt/mL = 30 gtt/min.

A patient is to receive 200 mg of fluconazole (Diflucan) by intravenous (IV) piggyback over the next hour. The piggyback bag containing the fluconazole has a total of 120 mL and the drop factor of the administration set is 15 gtt/mL. How many drops per minute are needed to administer the 200 mg of fluconazole in 1 hour?

ANS: D Systemic antifungal drugs have many common side effects, including loss of taste or changes in how food tastes. Unless this problem interferes with the patient's nutritional status, it is of no consequence. The patient should be reassured that the taste changes are an expected side effect and that normal taste sensation will return after the drug has been stopped after several days or a week.

A patient prescribed a systemic antifungal drug reports a change in how food tastes. What is your best action? a. Document the report as the only action. b. Hold the dose and notify the prescriber immediately. c. Caution the patient to wear sunglasses and a hat when outside. d. Reassure the patient that this is a common side effect of the drug.

ANS: C A positive reaction to a TB skin test requires that the skin around the injection site be indurated, not just red. Induration is caused by infiltration of the skin around the test site with many white blood cells, making the area red and swollen, and the tissue much harder than the surrounding normal skin. Bruising is a result of bleeding into the injection site, not infiltration and induration from white blood cells.

A patient received a tuberculosis skin test injection of purified protein derivative (PPD) 72 hours ago. Which assessment finding of the test site should be interpreted as a positive reaction? a. The injected area has a blister-like swelling about 2 mm high and 2 mm in diameter. b. The injection site is puffy and soft with pus oozing from the needle hole. c. The skin is red and very hard for 12 mm around the injection site. d. There is a large bruise surrounding the injection site.

ANS: B The WBC count, lactate dehydrogenase, and hematocrit values are abnormal; however, only the lactate dehydrogenase level is very high (three to four times normal). This value indicates liver impairment, which can be caused by taking ketoconazole. This value must be reported immediately so that liver function can be explored and any needed changes in drug therapy made before irreversible liver damage occurs.

A patient taking ketoconazole (Nizoral) for the last 2 weeks has all of the following blood laboratory test values. Which value should you report to the prescriber immediately? a. White blood cell count (WBC) 10,500 cells/mm3 b. Lactate dehydrogenase 880 IU/L c. Potassium 3.6 mEq/L d. Hematocrit 32%

ANS: D Peripheral neuropathy with loss of sensation in the extremities is a common and expected side effect of flucytosine therapy. Drug therapy is not stopped for this effect. The patient must implement precautions to prevent injury from not having full sensation for touch, temperature, and pressure.

A patient who has been prescribed flucytosine (Ancobon) reports reduced sensation in the fingers and toes. What is your best action? a. Document the report as the only action. b. Hold the dose and notify the prescriber. c. Remind the patient to continue the drug as usual and to take a multiple vitamin daily. d. Reassure the patient that this is an expected drug side effect and to use injury precautions.

ANS: B Ethambutol at high doses can cause optic neuritis vision changes that include reduced color vision, blurred vision, and reduced visual fields. This problem can lead to blindness. When the problem is discovered early, the eye problems are usually reversed when the drug is stopped.

A patient who is prescribed ethambutol (EMB, Myambutol) reports trouble distinguishing colors. What is your best action? a. Document the report as the only action. b. Hold the dose and notify the prescriber immediately. c. Caution the patient to wear sunglasses and a hat when outside. d. Reassure the patient that this is a common side effect of the drug.

ANS: C Both pyrazinamide and ethambutol increase uric acid production and increase the risk for gout attacks. Drinking more water can help prevent the uric acid crystals from precipitating in joints or kidneys.

A patient who is prescribed pyrazinamide and ethambutol for active tuberculosis (TB) also has gout. What adjustments will this patient's condition require? a. Gout is not affected by TB drug therapy, and no adjustments are needed. b. The prescribed therapy will improve gout and reduce the need for drug therapy to treat gout. c. The prescribed therapy increases the risk for gout attacks, and the patient should increase his or her intake of water. d. The drugs for treatment of gout interact with the drugs for TB, and the patient must not take the gout drugs within 2 hours of taking the TB drugs.

ANS: B Ketoconazole increases sun sensitivity and increases the risk for severe sunburn. Patients taking the drug should avoid direct sunlight, use sunscreen, and wear protective clothing whenever they are outdoors to prevent a severe sunburn. They should also avoid tanning beds and salons.

A patient who is very immunosuppressed is prescribed ketoconazole (Nizoral) for prevention of a fungal infection. Which statement made by this patient indicates the need for more teaching? a. "I will stop taking the drug if I should become pregnant." b. "I will stay in the sun as much as possible to avoid catching an infection." c. "I will avoid drinking alcoholic beverages during the time I am on this therapy." d. "If I miss a dose, I will take it as soon as I remember it and not wait until the next day."

ANS: 5 1 kg = 2.2 lb. Patient's weight in kilogram = 100 kg (220/2.2 = 100). 100 kg 2 kg/mg = 2000 mg (or 2 g). Want 2000 mg, Have 400 mg/tablet. 2000/400 = 5 tablets.

A patient who weighs 220 lb is prescribed 20 mg/kg of ethambutol (EMB). The ethambutol tablets available 400 mg/scored tablet. How many tablets will you give?

ANS: B Rifampin normally turns urine an orange color. No intervention is needed; however, the color change can be very distressing to patients. The patient should be reassured that this color change is normal and be taught how to manage this change so that clothing does not become stained.

A patient with active tuberculosis who has been taking isoniazid (INH, Nydrazid) and rifampin (RIF, Rifadin) reports having urine that is an orange color. What your best action? a. Obtain a specimen for culture and test the urine for occult blood. b. Reassure the patient that this is a normal drug side effect. c. Hold the dose and contact the prescriber. d. Document the report as the only action.

ANS: B A positive skin test for TB only means that the patient was infected with TB at one time. A TB scar also only indicates old, inactive disease. Cavitation and productive cough along with a positive skin test are indicators of active disease that can be spread to others, and this person must be treated. The person with a negative skin test and chest x-ray but with other symptoms probably has another type of respiratory infection.

A patient with which findings requires drug therapy for active tuberculosis (TB)? a. Negative TB skin test and chest x-ray but who has productive cough, fever, and shortness of breath b. Positive TB skin test, productive cough, and a cavitation on chest x-ray c. Positive TB skin test and a TB scar on chest x-ray d. Positive TB skin test as the only symptom

ANS: B, E, F The risk for liver toxicity is higher when taking TB drug therapy during pregnancy, and close monitoring of liver function is needed. In addition, the pregnant woman needs higher doses of a B-complex vitamin supplement when taking INH. Avoiding alcohol during TB therapy is very important for all patients and is critical for pregnant women because of the increased risk for liver toxicity as well as fetal alcohol syndrome.

A pregnant patient is taking all four first-line drugs for tuberculosis (TB). Which additional health care actions are needed for this patient? (select all that apply) a. Ensuring that no weight is gained b. Checking liver function tests monthly c. Checking vision and intraocular pressure monthly d. Testing urine for the presence of the TB organism e. Supplementing with B-complex vitamins f. Avoiding alcoholic beverages

ANS: D Ethambutol can cause serious eye problems that may lead to blindness in people of any age. Its use is avoided in children because they may not recognize vision changes caused by the drug soon enough to avoid permanent vision changes or blindness.

Which antitubercular drug is avoided in the treatment of children who have tuberculosis? a. Isoniazid (INH) b. Rifampin (RIF) c. Pyrazinamide (PAS) d. Ethambutol (EMB)

ANS: B, D, E Expected responses of first-line antituberculosis drugs include cough is reduced; sputum production is reduced; fatigue is reduced; weight is gained; and sputum culture is negative for TB organisms.

Which changes are intended responses of first-line antituberculosis drugs? (select all that apply) a. Sputum is mobilized (increased). b. Cough is decreased. c. Fatigue is eliminated. d. Weight is gained. e. Sputum culture for TB is negative. f. Future TB tests are negative.

ANS: B, D, E Most of the antifungal drugs can affect cardiac rhythm. Patients should check their pulse daily for a full minute, and if new irregularities are present or the rate is slow, the prescriber should be notified. The risk for drug-induced liver toxicity is higher among older adults; often the first symptom of reduced liver function is yellowing of the sclera and skin. Older adults are also more likely to have some degree of renal insufficiency and can develop kidney problems more quickly while taking an antifungal drug; normal daily urine output should be very close to the volume of fluid taken in each day. There is no recommendation to avoid caffeine with any antifungal drug. GI infection is not a specific risk associated with antifungal therapy. Abdominal bloating and diarrhea are not especially associated with antifungal therapy and are not indications of the need to seek immediate medical attention.

An older adult patient is prescribed systemic antifungal therapy for 1 month. Which precautions are important to teach this patient? (select all that apply) a. "Avoid drinking coffee or any other beverages or food that contain caffeine." b. "Check your pulse daily and report any new irregularities to your prescriber." c. "Examine all bowel movements and any vomit for the presence of pus and report it to your prescriber." d. "Look at the whites of your eyes daily and if a yellow color appears, report it to your prescriber." e. "If your daily urine output drops below a liter less than your daily fluid intake, notify your prescriber immediately." f. "If you should develop abdominal bloating and diarrhea, go to the nearest emergency department as soon as possible."

ANS: D The activity of azole antifungal drugs can be reduced by grapefruit juice in large quantities. Patients should not take an azole with grapefruit juice and should limit their total grapefruit juice intake to no more than 24 ounces/day.

Which class of antifungal agents should never be given with grapefruit juice? a. Echinocandins b. Alyamines c. Polyenes d. Azoles

ANS: D The four first-line drugs to treat tuberculosis are isoniazid, ethambutal, rifampin, and pyrazinamide. Amphotericin is an antifungal drug.

Which drug is NOT one of the "first-line" antitubercular drugs? a. Isoniazid (INH) b. Rifampin (RIF) c. Pyrazinamide (PAS) d. Amphotericin (AMT)

ANS: C Teach all patients on TB drug therapy to avoid alcoholic beverages and acetaminophen for the entire therapy period. Both alcohol and acetaminophen are toxic to the liver and so are the antitubercular drugs. Taking all of these drugs and either acetaminophen or drinking alcohol greatly increases the risk for permanent liver damage.

Which drug must a patient be taught to avoid during TB drug therapy? a. Aspirin b. Ibuprofen c. Acetaminophen d. Iron supplements

ANS: C A patient who has nondrug-resistant tuberculosis must remain on the prescribed medications for at least 6 months. The organism is slow growing and is harder to control than other types of bacteria.

How long is the minimum course of drug therapy for an immunocompetent patient with active tuberculosis? a. 7 to 10 days b. 6 weeks c. 6 months d. 2 years

ANS: C The drug can affect how the kidney reabsorbs or excretes potassium. A serum potassium level of 2.2 is very low and could lead to serious problems. The low potassium level is likely to cause greater problems in an older adult.

Which laboratory value in a 76-year-old woman on systemic fluconazole (Diflucan) therapy should you report immediately to the prescriber? a. Hematocrit of 38% b. Bilirubin of 0.4 mg/dL c. Potassium of 2.2 mEq/L d. Blood urea nitrogen (BUN) of 12.2 mg/dL

ANS: B The tuberculosis (TB) bacteria are spread when bacteria-filled droplets travel through the air when a person with TB coughs, laughs, sneezes, sings, or whistles. These droplets can be inhaled by another person who then may develop the disease. Bacteria-filled droplets in the air are known as "aerosol transmission." It is possible to spread TB in other ways but aerosol transmission is by far the most common.

What is the major way in which tuberculosis is spread from one person to another? a. By blood transfusions b. By aerosol transmission c. Through direct skin contact d. From unprotected sexual intercourse

ANS: C The IV form of rifampin contains a sulfite preservative that can cause hypersensitivity reactions in patients allergic to sulfite preservatives such as sodium metabisulfite or potassium metabisulfite. This problem is not the same as an allergy to "sulfa" drugs.

What is the most important question to ask a patient before administering rifampin (RIF) intravenously? a. "Have you ever had gout?" b. "Are you allergic to sulfa drugs?" c. "Are you allergic to sulfite preservatives?" d. "Have you had any alcoholic beverages within the last month?"

ANS: A Antifungal drugs that are applied topically do not penetrate tissues and only work against fungi that are on the surface.

What type of fungal infections can be treated with topical antifungal agents? a. Those that are confined to the skin or mucous membranes b. Those that are located under the toenails or fingernails c. Those that are infected by only one specific type of fungus d. The type that only infect humans and not animals

ANS: A Successful drug therapy for TB requires that all first-line drugs be taken correctly without missing doses. Patients who have memory problems usually need some form of directly observed therapy (DOT) to ensure absolute adherence to this important therapy. Having one family member responsible for giving the drugs fulfills the requirements of DOT and reduces the risk that the patient will receive either too many drug doses or too few doses to be effective.

Which administration technique should you teach the family of a patient with memory problems for best adherence to first-line drug therapy for tuberculosis? a. Having one family member responsible for giving the drugs and watching the patient swallow them b. Setting up the patient's drugs using a daily pill dispenser that has separate slots for each individual drug c. Asking the patient every night whether he or she has remembered to take all the drug doses that day d. Administering all the drugs together at the same time every day and ensuring that the patient drinks plenty of water

ANS: A Amphotericin B causes massive vasodilation, especially if given too fast, which results in whole body flushing and a red appearance.

Which antifungal drug causes "red man syndrome?" a. Amphotericin B b. Ketoconazole c. Caspofungin d. Fluconazole

ANS: A Although some antifungal drugs have the potential to affect renal function if given at higher doses or for prolonged periods, only amphotericin causes renal impairment in everyone who receives it even if they only receive one dose.

Which antifungal drug causes some degree of renal impairment in everyone who receives it? a. Amphotericin (Amphocin) b. Terbinafine (Lamisil) c. Caspofungin (Cancidas) d. Fluconazole (Diflucan)

ANS: C Micafungin and amphotericin B are administered intravenously. Although flucytosine can be administered orally, it is not available as granules and is not prescribed for ringworm.

Which antifungal drug to treat ringworm is given to children as granules that are sprinkled over soft, nonacidic foods? a. Amphotericin B b. Flucytosine c. Terbinafine d. Micafungin

ANS: B Rifampin is associated with discoloration of the urine, which turns a reddish orange or a reddish brown color. The cause of this discoloration is not known but may be related to the drug's action of increasing the renal excretion of bile acids.

Which antitubercular drug causes the urine to turn reddish orange? a. Isoniazid (INH) b. Rifampin (RIF) c. Pyrazinamide (PAS) d. Ethambutol (EMB)

ANS: D Isoniazid raises blood pressure. When this drug is taken in combination with other drugs or agents that also raise blood pressure, the patient can develop dangerous hypertension. Caffeine is a common food ingredient that greatly increases the risk for hypertension when taken in combination with isoniazid.

Which precaution is most important to teach a patient who is prescribed isoniazid (INH, Nydrazid)? a. "Use another form of birth control in addition to oral contraceptives to prevent an unplanned pregnancy." b. "Do not drive or operate dangerous equipment until you know how this drug affects you." c. "Wear glasses rather than contact lenses throughout this drug therapy." d. "Avoid coffee and any foods or beverages that contain caffeine."

ANS: B, D, E Sexual intercourse should be avoided for several reasons: the drug can make holes in a condom or diaphragm and increase the risk for an unplanned pregnancy; in addition, the infection can be spread to a sexual partner. The applicator should be washed regularly with soap and water after each use. Although hands should be washed before and after applying the drug, the vagina is not a sterile body cavity, so it is not necessary to wear gloves during the application. There are no bathing restrictions while using the drug. Vaginal application of the drug does not affect pregnancy (however, a vaginal infection can have adverse effects on the pregnancy). To ensure eradication of the infection and prevent the development of resistant organisms, the drug should be used for as long as prescribed even after symptoms are no longer present.

Which precautions are important to teach a woman using a vaginal cream form of an antifungal drug? (select all that apply) a. Wear gloves to insert the cream. b. Wash the applicator with soap and water. c. Do not tub bathe until treatment is completed. d. Avoid sexual intercourse during the treatment period. e. Remind the patient that the cream can make holes in a condom or diaphragm. f. Stop the drug immediately if you think you are pregnant. g. Stop the drug when symptoms have disappeared to avoid unnecessary exposure to it.

ANS: C TB is the most common bacterial infection worldwide. However, it requires an overwhelming exposure in a susceptible host to develop the disease. Therefore many more people are exposed to and take in the bacteria than who actually go on to develop the disease.

Which statement about tuberculosis (TB) is true? a. The lungs are the only organ ever affected by TB. b. A positive TB test means the person has active tuberculosis. c. Far more people are infected with TB than actually develop the disease. d. Any redness in the area where the TB test was performed is considered positive.

ANS: D Usually TB is no longer contagious and clinical improvement is seen after drugs have been taken for 2 to 3 consecutive weeks. However, the organism growth has only been suppressed and the immune system and drugs have not had sufficient time to eradicate it. Stopping treatment after only a month will allow the disease to again become active and the organisms can become resistant to these drugs. The patient must continue taking the drugs for 6 months or longer, exactly as prescribed.

Which statement made by a patient indicates the need for more teaching about first-line drug therapy for tuberculosis (TB)? a. "To prevent nausea/vomiting, I have been taking my drugs at night with a small snack." b. "I have stopped taking all herbal supplements and stopped drinking beer until I finish this drug therapy." c. "Now that my symptoms have disappeared after a month of drug therapy, I can no longer infect my family." d. "Now that my symptoms have disappeared after a month of drug therapy, I can stop taking all of these drugs."

ANS: C Warn patients taking terbinafine or flucytosine for more than 1 week that they are at an increased risk for infection and should avoid crowds and people who are ill.

Which teaching point should you stress when a patient is prescribed terbinafine (Lamisil)? a. Avoid citrus fruits while taking this drug. b. Do not drive until you know how the drug affects you. c. Stay away from crowds or people who are ill. d. Get lots of extra rest while you are taking this drug.

ANS: A Because the TB organism is slow growing, many common antibacterial drugs are not effective in controlling or killing it. Combination drug therapy with agents effective against the TB organism is needed to treat TB and prevent its transmission.

Why are most standard antibacterial drugs ineffective against tuberculosis? a. The TB organism is slow growing. b. The TB organism is not really a type of bacteria. c. The TB organism does not have a true cell wall. d. The TB organism is usually located in the brain stem where antibacterial drugs cannot reach.

ANS: B Fungi have many differences from bacteria that make antibacterial drugs less effective or not at all effective in controlling their growth. Fungi have a tough, thick cell wall and a hardy plasma membrane. Antibacterial drugs are not able to penetrate the thick cell wall or disrupt the plasma membrane.

Why are standard antibacterial drugs ineffective against fungal infections? a. Funguses are slow growing. b. Funguses have a thick cell wall. c. Fungal infections usually occur in the brain stem where antibacterial drugs cannot reach. d. Fungal infections have so few symptoms that most people are unaware of the problem until the infection is widespread.

ANS: C Ethambutol is only bacteriostatic. When taken alone, it cannot eradicate the tuberculosis bacteria and cure the disease.

Why is ethambutol always used in combination with other antitubercular drugs? a. Its presence enhances or potentiates the other first-line antitubercular drugs. b. Its side effects are more serious when taken alone. c. It is only bacteriostatic and not bactericidal. d. It is not a first-line antitubercular drug.