Chapter 17 Quiz 1 (antibiotics/antibacterial)

Contraindications and warnings of Tetracyclines:

- Pregnancy, lactation, and children under age 8 - patients exposed to direct sunlight - caution in patients with liver or GI disease - Patients with renal disease (doxycycline preferred)

Cephalosporin side effects can include;

- hypersensitivity, including rash, edema, or anaphylaxis especially in those allergic to penicillin - blood dyscrasias (for example increased bleeding time or transient leukopenia) renal toxicity, especially in older patients, mild hepatic dysfunction - nausea, vomiting, and diarrhea - phlebitis with IV Administration and pain at site of IM injection, respiratory distress, seizures Contraindications or Extreme Caution applies to; -known allergies, especially to penicillin (3% - 7% cross sensitivity more so with first generation cephalosporins) - prolonged use possibly leading to Super infections or severe colitis cephalosporin interactions can include; -increased effectiveness with probenecid, -disulfiram like reaction (for example Flushing, tachycardia, shock) with alcohol ingestion and cefotetan

Strategies to prevent resistance:

-Appropriate use of anti-infectives •Better education of provider and patients -Accurate diagnosis -Targeted treatment of bacterial infections -Preventive measures

aminoglycosides

-aminoglycosides e.g. Gentamicin in combination with other antibiotics are used to treat many infections caused by gram-negative bacteria e.g. escherichia coli and pseudomonas as well as gram-positive bacteria e.g. staphylococcus aureus enterococci may be resistant to aminoglycosides - are used in the short-term treatment of many serious infections (e.g bacteria in the blood stream causing very low blood pressure) - because of poor absorption from the gastrointestinal GI tract aminoglycosides are usually administered parenterally i.e. IM or IV •Gram-negative and gram-positive bacteria •Toxicity •Peak and trough levels •Serious side effects: -Nephrotoxicity -Ototoxicity -Neuromuscular blockade -CNS symptoms with aminoglycosides patients should be instructed regarding; extreme importance of close medical supervision during therapy. careful observation of intake and urinary output. Prompt reporting of any side effects, especially kidney or hearing problems

patients being treated with tetracyclines should be instructed

-avoiding exposure to -avoiding this medication is pregnant or nursing or a child under 8 years of age -Administration preferable on an empty stomach with full glass of water 1 hour before or two hours after meals unless there is gastric distress - avoiding iron, calcium, magnesium, and anti-diarrheal agents or dairy foods within two hours of taking tetracyclines - not taking at bedtime to prevent irritation from esophageal reflux - discarding in the expired drug nephrotoxicity can result from taking updated drug

patients being treated with macrolides should be instructed regarding;

-common GI side effects to be - expected importance of reporting side effects for possible dosage adjustment or prescription of medication for symptomatic relief -taking medication with full glass of water 1 hour before or two hours after meals unless stomach upset some forms can be taken without regard to meals - including yogurt or buttermilk in diet may help regulate intestinal flora and reduce incidents of diarrhea -not taking with other medications

patients being treated with Penicillin should be instructed regarding

-discontinuance of medication and immediate reporting of any hypersensitivity reactions for example rash, swelling, or difficulty breathing - taking medication on time as prescribed on empty stomach, one hour before or two hours after meals, with full glass of water - avoidance of antacids and alcohol - effectiveness of estrogen contraceptives may be effective ( birth control)

side effects of amphotericin B

-headache, chills, fever, hypotension, tachypnea - malaise, muscle and joint pain, and weakness - anorexia, nausea, vomiting, and cramps - nephrotoxicity occurs to some degree in most patients - anemia - hypokalemia, hypomagnesemia

patients taking quinolones should be instructed regarding

-not taking other medication without Physicians approval - drinking liberal quantities of fluids - restricting caffeine intake see CNS effects - avoiding excessive exposure to the Sun - avoiding strenuous exercise during the several weeks after (therapy potential for cartilage or tendon damage) - reporting all side effects, especially rash or hypersensitivity signs - geriatric patients should follow proceeding instructions, especially reporting GI effects or CNS effects

Resistance

-organisms build up resistance to drugs that have been used too frequently and then are no longer effective

interactions of Aminoglycosides may occur with;

-other ototoxic drugs for example amphotericin B, polymyxin b, Bacitracin, and Vancomycin - General anesthetics or neuromuscular blocking agents for example succinylcholine which can cause respiratory paralysis - antiemetics May mask symptoms of vestibular ototoxicity

with cephalosporins patients should be instructed regarding

-possible allergic reactions, -avoidance of alcohol, -reporting any side effects to physician, -including buttermilk or yogurt in diet to restore normal intestinal Flora, -taking without regard to meals but with food if stomach upset occurs -attention to signs of abnormal bleeding (checking stools and urine for blood)

Contraindications or Extreme Caution with Aminoglycoside supplies to patients with;

-tinnitus and vertigo -reduced renal function -dehydration -pregnant or nursing women infants or older adults

adverse reactions to anti-infectives are divided into three categories

1. Allergic Hypersensitivity 2. Direct toxicity 3. Indirect toxicity, or superinfection see page 275 in chapter 17; for details on 1 - 3

The selection of ANTI-INFECTIVE drugs are based on several factors;

1. site of infection. this helps determine the initial empiric anti-infection regimen 2. status of hepatic and or renal function. lower doses or alternative drugs might be indicated with impairment 3. age of patient. some anti infectives are more toxic in children or the elderly. Lower doses or alternative drugs might be indicated. 4. pregnancy or lactation. Some anti-infectives can cross the placenta and cause damage to the developing fetus; for example, tetracycline or streptomycin. others can be carried in breast milk and can cause toxicity to the infant 5. likelihood of organisms developing resistance. sometimes a combination of drugs is used to decrease the chance of developing resistance to a single drug. Examples of combination therapy include sulfamethoxazole and trimethoprim combined to treat urinary tract infections. another example is the combination of three or more drugs to treat tuberculosis. 6. known allergy to the anti-infective drug. In such cases and alternative should be used.

interactions of quinolones may occur with

Theophylline- ciprofloxacin can potentiate serious or fatal central nervous system (CNS) effects, Cardiac Arrest, or respiratory failure - probenecid - increase blood levels of Cipro - antacids: decreased absorption - caumadin: increase risk of bleeding - preparations containing Fe, mg, Zn, Ca: decrease absorption (do not give within two hours) - sucralfate (carafate) contains aluminum ions which decrease absorption

Tigecycline (Tygacil)

a derivative of Minocycline, is a newer IV antibiotic approved for the treatment of intra-abdominal and skin structure infections caused by several microorganisms including MRSA. it should be reserved for more serious and resistant infections in order to maintain its full spectrum of activity

antifungals

agents are used to treat specific susceptible fungi the medications are quite different in action and purpose and are treated separately

anti-infective agents

aminoglycosides cephalosporins macrolides and penicillin see table 17-1 in page 282 drug classifications for generic name, trade name, and average dosage

anti-tuberculosis

are administered for two purposes one is to treat asymptomatic infection where no evidence of clinical disease for instance after exposure to active tuberculosis and or significant positive purified protein derivative PPD skin test and two for treatment of active clinical tuberculosis and to prevent relapse for a symptomatic tuberculosis the treatment consists of daily administration of ionized inh alone for six to 12 months to prevent development of the disease see page 288 chapter 17 for more information on INH

sulfonamides

are among the oldest anti-infectives, side effects are numerous and sometimes serious especially with AIDS patients and can include rash, pruritus, dermatitis, and photosensitivity. Nausea, vomiting and diarrhea. High fever, headache, stomatitis, and conjunctivitis, blood dyscrasias, hepatic toxicity with jaundice, renal damage with crystalluria and hematuria, hypersensitivity reactions, which can be fatal. contraindications or Warnings with sulphonamides include impaired hepatic function, impaired renal function or urinary obstruction, blood dyscrasias, severe allergies or asthma some studies suggest approximately 3% of the population is allergic to sulfa drugs, pregnancy or lactation interactions with sulfonamides include potentiation of anticoagulants and oral anti-diabetics, antagonism of local anesthetics example propane May inhibit antibacterial action of sulfa, potentiation of phenytoin Dilantin example increasing serum drug concentrations patients taking sulfonamides should be instructed regarding importance of drinking large amounts of fluid to prevent crystalluria. discontinuance of sulfa at first sign of rash. reporting any side effects to physician immediately. Avoiding exposure to sunlight. Ingestion of sulfur with food, which delays, but does not reduce, absorption of the drug

Penicillins;

are antibiotics produced from certain species of the fungus they are used to treat many streptococcal and some staphylococcal and meningococcal infections including respiratory and intestinal infections. penicillin is the drug of choice for treatment of syphilis and is also used prophylactically to prevent recurrences of rheumatic fever Serious side effects of penicillin can include; -hypersensitivity reactions ranging from rash to fatal anaphylaxis - super infections especially with oral ampicillin - nausea, vomiting, and diarrhea blood dyscrasias, which are reversible with discontinuance of drug - renal and hepatic disorders (rare) - CNS effects, for example, confusion, anxiety, seizures (especially with Penicillin G) contraindications or Extreme Caution with penicillins applies to patients with; -history of allergies, including asthma, eczema, or hay fever ( anaphylaxis has been reported with parenteral, oral, or intradermal skin testing) - treatment for severe reactions includes discontinuance of the drug, immediate Administration of appropriate medications (e.g. epinephrine and corticosteroids), and maintenance of the patient airway. Administration of antihistamines with Penicillin will not prevent hypersensitivity reactions

Tetracyclines;

are broad spectrum antibiotics used in the treatment of infections caused by rickettsia, chlamydia, or some uncommon bacteria. Side effects of Tetracyclines; -Nausea, vomiting, and diarrhea, (frequently dose related) - Superinfections, such as vaginitis, and stomatitis - Photosensitivity, with exaggerated sunburn - Discolored teeth in fetus or young children - Hepatic or renal toxicity (rare) - CNS symptoms such as vertigo and cerebral edema - Thrombophlebitis possible with IV therapy - Allergic hypersensitivity reactions rare

Erythromycin

are considered among the least toxic antibiotics and are therefore preferred for treating susceptible organisms under conditions in which more toxic antibiotics might be dangerous for example in patients with renal disease, pregnant patients, or small infants

Cephalosporins

are semi synthetic antibiotic derivatives produced by a fungus they are related to the penicillins and some patients allergic to penicillin are also allergic to cephalosporins. cephalosporins are classified as 1st 2nd 3rd or 4th Generations according to the organisms susceptible to their activity see page 278 in chapter 17 drug classifications for more info •Semisynthetic •Broad-spectrum •First, second, third, or fourth generation •Side effects

urinary anti-infectives

are usually bacteriostatic instead of bacteriocidal in action. side effects of nitrofurantoin can include nausea and vomiting, which are less frequent if taken with milk or food, numbness and weakness of lower extremities. Headache, dizziness, and weakness of muscles. Respiratory distress with prolonged use. Brown uterine. anemia. contraindications or caution with furadantin and macrodantin applies to renal or hepatic impairment, anemia, diabetes, electrolyte abnormalities, asthma, pregnancy and lactation, children under one month of age. interactions of nitrofurantoin antagonistic with probenecid and magnesium, antacids containing magnesium decreasing the effectiveness of these drugs, quinolones patients taking nitrofurantoin should be instructed regarding importance of taking medication for required number of days. Reporting side effects. Taking medication with milk or food to reduce incidence of nausea and vomiting. Avoiding antacids. Discoloration of the urine, which and stained Underpants.

erythromycin warning

can cause abnormal, potentially fatal, cardiac arrhythmias when combined with the following drugs, which increase its concentration in the blood: calcium channel blockers Verapamil or diltiazem - anti-arrhythmic agents - azole antifungals for example fluconazole (Diflucan) quinolones

griseofulvin side effects

headache which is frequent initially also thirst nausea vomiting and diarrhea as well as hypersensitivity reactions causing rash urticaria also photosensitivity and hepatic toxicity contraindications or Warnings include children under the age 2 pregnancy or women who may become pregnant while taking the drug liver dysfunction porphyria and penicillin hypersensitivity possible cross sensitivity interactions may occur with alcohol, causing flushing and tachycardia also phenobarbital which is antagonistic two griseofulvin action which means impairs absorption also warfarin which decrease Prothrombin time decrease anticoagulant effect as well as oral contraceptives which made a crease contraceptive efficacy

amphotericin B

is administered IV for the treatment of severe systemic potentially fatal infections caused by susceptible fungi sometimes considered the drug of choice to treat severe fungal infections resulting from immunosuppressive therapy or in patients with acquired immunodeficiency syndrome AIDS or those with severe illness severe side effects are expected and therefore close medical supervision is usually required so that measures are available to provide symptomatic relief in the hospital example antipyretics antihistamines and antiemetics

Griseofulvin

is administered by mouth in the treatment of specific fungi causing tinea infections example ringworm or at least for the that do not respond to topical agents

MRSA ( methicillin-resistant staphylococcus aureus)

is an example of an organism resistant to most antibiotics

Vancomycin IV

is one of the small number of drugs effective against MRSA. some strains of enterococci have become resistant to most of the antibiotics including Vancomycin. infections such as bacteremia endocarditis or urinary tract infections UTIs which are caused by Vancomycin resistant enterococci VRE can be very difficult to treat

antivirals Acyclovir

is used predominantly in the treatment of herpes simplex, herpes zoster shingles, and varicella zoster chicken pox infections. see page 296 for more information side effects of Acyclovir are not common but can include impaired renal function, especially with rapid IV infusion. Lethargy, Tremors, confusion, and headache, especially with older adults. Rash, urticaria, pruritus and photosensitivity. nausea, vomiting, abdominal pain, and diarrhea. contraindications or caution with acyclovir include children, breastfeeding, renal disease adjust doses patients being treated with Acyclovir should be instructed regarding the fact that acyclovir is usually effective only with initial infection and relieving pain and shortening healing of lesions, but is not a cure and there can be reoccurrence is of lesions. reporting side effects. Taking medicine only as prescribed. Do not share drug with others. Finish full course prescribed, even if feeling better. Avoidance of sexual intercourse when visible genital herpes lesions are present and using protection at other times

Nystatin

is used to treat oral cavity candidiasis is also used as a fungicide in the topical treatment of skin and mucous membranes for example diaper area mouth or vagina side effects are rare but may include nausea vomiting and diarrhea with high oral doses occasionally caution should be taken in the use of Nystatin with pregnant or nursing women patients on antifungal therapy should be instructed regarding taking the medication for prolonged periods as prescribed even after symptoms have subsided. Reporting relapses promptly to physician. Reporting side effects immediately to The Physician for possible dosage adjustment or symptomatic treatment. Not taking any other medications at the same time without physician approval.

fluconazole interactions

may occur with Warfarin which will increase Prothrombin time and could cause hemorrhoids also oral antidiabetic agents which hypoglycemia can result also Rifampin that can lead to clinical failure of fluconazole and also statins accept Pravastatin which increase risk of myopathy

Interactions of Tetracyclines:

may occur with the following antagonists (which decrease absorption) - antacids, calcium, supplements, or magnesium laxatives

INH side effects

nausea, vomiting, and diarrhea. Dizziness, blurred vision, headache, and fatigue. Numbness, weakness of extremities. Hepatic toxicity where is specially those over 35 and children. body fluids colored red orange with Rifampin. Hypersensitivity reaction, with flu-like symptoms. contraindications or caution with inh and Rifampin applies to Chronic liver disease or alcoholics, periodic laboratory tests required. Impaired renal function. Children's doses of inh and Rifampin should be limited to 10 and 15 milligrams per kilogram, respectively, to decrease likelihood of hepatic toxicity. interactions with Rifampin include antagonism by Oral hypoglycemics, corticosteroids, digitalis, anticoagulants, and estrogen, serum levels of these drugs are reduced when taking Rifampin. Decrease in the serum concentration of antiretroviral protease inhibitors PIs which may result in HIV treatment failure. interactions with inh include potentiation by phenytoin Dilantin increased action possible toxicity when taking with isoniazid. increased risks of hepatotoxicity with Rifampin vs each agent alone. Alcohol, which increases possibility of liver toxicity with both inh and Rifampin side effects of ethambutol can include optic neuritis with visual problems reversible if discontinued early. Dermatitis, pruritus, headache, malaise, fever, confusion, joint pain, GI symptoms, peripheral neuritis rarely cautions and contraindications with ethambutol include: visual testing should be performed before and during therapy. Impaired renal function reduced doses indicated. Diabetes, especially diabetic retinopathy. ocular defects. Children under 13 and only in children whose visual acuity can accurately be determined and monitored. pregnancy caution. Patients with gout ethambutol can cause hyperuricemia side effects of pyrazinamide include: hepatic toxicity. Gout increase uric acid. Hypersensitivity. GI disturbances contraindications and warnings with pyrazinamide: renal failure or history of gout, diabetes, severe hepatic disease or alcoholism, children potential toxicity, pregnant or nursing women side effects of streptomycin, common to all aminoglycosides, include ototoxicity and nephrotoxicity see page 290 chapter 17 for patient education on taking anti-tuberculosis agents and instructions on how to take

contraindications or caution with quinolones applies to

older adults, especially with GI disease or arteriosclerosis - children or adolescents potential for cartilage damage - strenuous exercise during and the several weeks after therapy potential for tendon rupture - pregnancy and lactation -seizure disorders - cardiac disease (may cause or contribute to cardiac arrhythmias)

interactions of penicillins include

potentiation of penicillin with probenecid, which may be desirable potentiation with anti-inflammatory drugs such as methotrexate and salicylates given concomitantly (at the same time) monitor for increased side effects - antagonistic effect (delayed absorption) of oral penicillins when given with antacids or with food - antagonistic effect of some other anti-infectives on penicillin penicillin V or ampicillin may inhibit the action of estrogen containing oral contraceptives ( birth control)

antibiotics

should not be used for the common cold which is caused by a virus and not bacteria

Vancomycin

side effects can include ototoxicity or nephrotoxicity occurred primarily with older and pure formulations with IV use, discontinued with tinnitus, May proceed deafness. local effects give only ivy with care, can cause necrosis or thrombophlebitis. rash, anaphylaxis, vascular collapse hypersensitivity reactions reported in 5% to 10% of patients. Pseudomembranous colitis due to clostridium difficile infection -rare caution for Vancomycin with older adults, hearing impaired, renal impairment ( serum drug levels are often drawn to determine optimal dosing to maximize efficacy against MRSA. kidney function is also monitored frequently by serum creatinine and Bun to determine dosage adjustments. contraindicated with pregnancy and lactation see page 293 chapter 17 for more information

ribavirin

side effects can include respiratory complications, hypotension, Cardiac Arrest, anemia, rash, conjunctivitis contraindicated during pregnancy or lactation. Healthcare practitioners and visitors who are pregnant or lactating should be warned about the serious risk, of close contact with patients receiving ribavirin inhalation therapy. also contraindicated for older adults and those with cardiac disease interaction of ribavirin with nrti's, agents for HIV, depending on specific agent, can antagonize antiviral action against HIV, cause lactic acidosis, cause hepatic failure

side effects of Macrolides

side effects from macrolides of a serious nature are rare, and Mild side effects, usually dose-related, can include -anorexia, nausea, vomiting, diarrhea, and cramps, -Urticaria & rash, - super infections, - serious side effects can occur with some interactions

metronidazole

side effects of Flagyl include abdominal pain, nausea vomiting, anorexia, metallic taste, xerostomia, headache, dizziness, ataxia, flushing, rash, urticaria, peripheral neuropathy rare, and seizures, dark urine common but harmless contraindications and precautions with flagyl include avoid alcohol during the 48 hours after treatments you get a disulfiram reaction, history of blood dyscrasias, pregnancy especially during first trimester and lactation, used in children except for treatment of amebiasis, CNS and hepatic disease

clindamycin

side effects that frequently occur can include nausea, vomiting, diarrhea drugs should be discontinued if this develops, colitis, rash, pruritus, fever, and occasionally anaphylaxis, local effects: minimize by Deep IM more frequent IV catheter change see page 292 chapter 17 for more information

quinolones

such a ciprofloxacin or levofloxacin are used in adults for the treatment of some infections of the urinary tract, sinuses, lower respiratory tract, GI tract, skin, bones, and joints, and in treating gonorrhea. side effects of the quinolones -nausea, vomiting, diarrhea, abdominal pain, colitis especially older adult patients - CNS effects, headache, dizziness, confusion, irritability, seizures, anxiety - Crystalluria may require drinking liberal quantities of fluids - superinfection, treat infection appropriately, may need to stop drug - hypersensitivity reactions or rash is rare - phototoxicity, exposure to sunlight can cause severe sunburn - possible cartilage or tendon damage see page 283 chapter 17 for more information

macrolides

such as erythromycin clarithromycin and azithromycin are used in many infections of the respiratory tract and for skin conditions such as acne or for some sexually transmitted infections when the patient is allergic to penicillin •Used for infections of respiratory tract, skin conditions, and for some sexually transmitted diseases (STDs) when allergic to penicillin •Less toxicity •Gram-negative bacilli generally resistant -Other resistance increasing

fluconazole

the drug is appropriate for patients requiring prolong antifungal therapy it is used in the treatment of oropharyngeal thrush and esophageal candidiasis and serious systemic candidal infections example urinary tract and bloodstream infections fluconazole side effects moderate nausea vomiting abdominal pain diarrhea rash hepatic abnormalities dizziness and headache fluconazole contraindications or Extreme Caution pregnant or nursing women and hepatic or renal disease

Serious side effects from Aminoglycosides

the side effects affect the older adults dehydrated patients or those with renal or hearing impairment especially - nephrotoxicity, General irreversible upon discontinuation - ototoxicity, both auditory hearing loss and vestibular vertigo may be permanent - neuromuscular blockade, including respiratory paralysis - CNS symptoms include headache, Tremor, lethargy, numbness, seizures blurred vision, rash, or urticaria

macrolides interactions

these macrolides erythromycin and Clarithromycin but not azithromycin may occur with potentiation of the following drugs and possible toxicity: -carbamazepine (Tegretol) -Ataxia, dizziness, drowsiness - cyclosporine (immunosuppressant with kidney/ liver transplant) - Theophylline - benzodiazepines: potentiation of sedative effects - Warfarin May prolong Prothrombin time and bleeding - digoxin - statins: leading to myopathy

patients taking antibiotics should be instructed regarding

unless directed otherwise, thanking all antibiotics with a full glass of water on empty stomach, at least 1 hour before meals or two hours after meals. Not taking with fruit juice, not taking with antacids, not taking with alcohol, if side effects occur, discontinuing medication and Consulting the position or pharmacist, reporting rash, swelling, or breathing difficulty to the physician immediately. taking antibiotics at prescribed times to maintain blood levels. Taking entire prescription completely, not discontinuing when symptoms of infection disappear. not taking any other medications, prescriptions, or over-the-counter drugs at the same time as antibiotics without checking first with the position or pharmacist regarding interactions

agents for VRE

zyvox and cubicin side effects of zyvox can include nausea, headache, diarrhea stop medication and contact physician with blood in stool or adominal pain. Myelosuppression including anemia and thrombocytopenia. lactate acidosis. Pseudomembranous colitis contraindications or caution with zyvox applies to blood disgracias, cardiac disease, hypertension, GI disease, hyperthyroidism, pregnancy, lactation, infants interactions of zyvox may occur with beta blockers that can worsen bradycardia. radiographic contrast media increase risk of Caesars, antidepressants example ssris can cause serotonin syndrome, migraine medications triptans, sympathomimetics such as phenylephrine, Cinderella friend, Foods or beverages with high tyramine content side effects of cubicin can include constipation, nausea, injection site reactions, and headache. elevated levels of creatinine phospho kinase, leading to myopathy monitor CPK levels weekly contraindications or caution with cubicin applies to renal impairment, dosage adjustments required and severe disease. Pneumonia, daptomycin is inactivated by pulmonary surfactant and therefore is ineffective.