Chapter 87: Aminoglycosides: Bactericidal Inhibitors of Protein Synthesis

A patient is receiving an aminoglycoside (tobramycin) antibiotic. A nurse asks the patient to choose daily meal selections, to which the patient responds, "Oh, dear, I don't want another IV." The nurse makes which assessment about the patient's response? A) Some hearing loss may have occurred. B) The confusion is due to the hospital stay. C) A nutrition consult most likely is needed. D) The patient has a family history of dementia.

A; The patient's comment suggests that the person did not hear the instructions. Aminoglycoside antibiotics can cause ototoxicity. The first sign may be tinnitus (ringing in the ears), progressing to loss of high-frequency sounds. Audiometric testing is needed to detect it. Nutrition, confusion, and a family history of dementia do not address the problem of possible hearing loss associated with aminoglycosides.

A patient who has been receiving intravenous gentamicin for several days reports having had a headache for 2 days. The nurse will request an order to: a. obtain a gentamicin trough before the next dose is given. b. give an analgesic to control headache discomfort. c. reduce the dose of the gentamicin to minimize side effects. d. obtain renal function tests to evaluate for potential nephrotoxicity.

ANS: A A headache may be a sign of developing ototoxicity, so a gentamicin trough should be obtained before the next dose is given. Analgesics are not indicated until a serious cause of the headache has been ruled out. Reducing the dose without first knowing the level would not be indicated. A headache is an early sign of ototoxicity, not nephrotoxicity.

A nurse is explaining to nursing students why a cephalosporin is used in conjunction with an aminoglycoside for a patient with an infection. Which statement by a student indicates understanding of the teaching? a. "Cephalosporins enhance the actions of aminoglycosides by weakening bacterial cell walls." b. "Cephalosporins prevent neuromuscular blockade associated with aminoglycosides." c. "Cephalosporins prolong the postantibiotic effects of the aminoglycosides so doses can be decreased." d. "Cephalosporins reduce bacterial resistance to aminoglycosides."

ANS: A Cephalosporins, penicillins, and vancomycin can be used in conjunction with aminoglycosides; these drugs weaken the bacterial cell wall and enhance the bactericidal actions of aminoglycosides. Cephalosporins do not prevent neuromuscular blockade. They do not prolong the postantibiotic effects of aminoglycosides. They do not affect bacterial resistance.

A patient who is taking gentamicin and a cephalosporin for a postoperative infection requests medication for mild postsurgical pain. The nurse will expect to administer which of the following medications? a. Acetaminophen b. Aspirin c. Ibuprofen d. Morphine

ANS: A Gentamicin and cephalosporins are both nephrotoxic. This patient should avoid taking other potentially nephrotoxic drugs. Acetaminophen is not nephrotoxic and may be given for mild pain. Aspirin and ibuprofen are both nephrotoxic. Morphine is not nephrotoxic but is not indicated for mild pain.

A patient is diagnosed with an infection caused by Staphylococcus aureus, and the prescriber orders intravenous gentamicin and penicillin (PCN). Both drugs will be given twice daily. What will the nurse do? a. Administer gentamicin, flush the line, and then give the penicillin. b. Give the gentamicin intravenously and the penicillin intramuscularly. c. Infuse the gentamicin and the penicillin together to prevent fluid overload. d. Request an order to change the penicillin to vancomycin.

ANS: A Gentamicin should not be infused with penicillins in the same solution, because PCN inactivates gentamicin; therefore, the nurse should give one first, flush the line, and then give the other. The nurse cannot give a drug IM when it is ordered IV without an order from the prescriber. These two drugs should not be infused in the same solution. There is no indication for changing the PCN to vancomycin; that should be done for serious infections.

A patient has a Pseudomonas aeruginosa infection that is sensitive to aminoglycosides, and the prescriber orders gentamicin. The patient tells the nurse that a friend received amikacin (Amikin) for a similar infection and wonders why amikacin was not ordered. What will the nurse tell the patient? a. "Amikacin is given when infectious agents are resistant to other aminoglycosides." b. "Amikacin is more vulnerable to inactivation by bacterial enzymes." c. "Amikacin is a narrow-spectrum drug and will probably not work for this infection." d. "Gentamicin is less toxic to the ears and the kidneys."

ANS: A Resistance to amikacin is uncommon at this point; to minimize the emergence of amikacin- resistant bacteria, this drug is reserved for infections in which resistance to other aminoglycosides has developed. Amikacin is the least susceptible to inactivation by bacterial enzymes. Amikacin is a broad-spectrum antibiotic. All aminoglycosides are ototoxic and nephrotoxic.

A patient is receiving tobramycin 3 times daily. A tobramycin peak level is 4.5 and the trough is 1.2. What will the nurse do? a. Give the next dose as ordered. b. Hold the next dose and notify the provider. c. Monitor the patient for signs of nephrotoxicity. d. Tell the patient to report tinnitus.

ANS: A These levels are within normal limits, so the next dose may be given safely. It is not necessary to withhold the next dose. These levels do not indicate any increased risk of nephrotoxicity or ototoxicity.

A patient is receiving gentamicin once daily. A nursing student asks the nurse how the drug can be effective if given only once a day. The nurse explains drug dosing schedules for aminoglycosides. Which statement by the student indicates a need for further teaching? a. "Gentamicin has a longer half-life than other aminoglycosides." b. "Large doses given once daily yield higher peak levels." c. "The postantibiotic effect lasts for several hours." d. "There is less risk of ototoxicity and nephrotoxicity with large daily doses."

ANS: A When a daily dose is given once daily instead of divided into 2 or 3 doses, a higher peak level can be achieved. The higher peak, along with the fact that aminoglycosides have a postantibiotic effect, means that the bacterial kill is just as great with one dose as with 2 or 3 doses per day. When a single daily dose is given, the risk of toxicity is reduced. Gentamicin does not have a longer half-life than other aminoglycosides.

A patient is admitted to the unit for treatment for an infection. The patient receives IV amikacin (Amikin) twice a day. When planning for obtaining a peak aminoglycoside level, when should the nurse see that the blood is drawn? a. 30 minutes after the IV infusion is complete b. 1 hour after the IV infusion is complete c. 1 hour before administration of the IV infusion d. A peak level is not indicated with twice-daily dosing.

ANS: A When divided daily doses are used, blood samples for measurement of peak levels are drawn 1 hour after IM injection and 30 minutes after completion of an IV infusion. This medication is administered IV, so blood draws must follow 30 minutes after infusion to obtain peak levels. Measurement of peak levels is unnecessary only when a single daily dose is used.

A patient is diagnosed with a lung infection caused by P. aeruginosa. The culture and sensitivity report shows sensitivity to all aminoglycosides. The nurse knows that the rate of resistance to gentamicin is common in this hospital. The nurse will expect the provider to order which medication? a. Amikacin (Amikin) b. Gentamicin c. Paromomycin d. Tobramycin

ANS: A When resistance to gentamicin and tobramycin is common, amikacin is the drug of choice for initial treatment of aminoglycoside-sensitive infections. Gentamicin would not be indicated, because resistance is more likely to develop. Paromomycin is used only for local effects within the intestine and is given orally. Tobramycin is not indicated, because organisms can more readily develop resistance.

A patient is receiving an intraperitoneal aminoglycoside during surgery. To prevent a serious side effect of this drug, the nurse expects to administer which agent? a. Amphotericin B b. Calcium gluconate c. Neuromuscular blocker d. Vancomycin

ANS: B Aminoglycosides can inhibit neuromuscular transmission, especially during intraperitoneal or intrapleural instillation, and this risk is increased when neuromuscular blocking agents and general anesthetics are given. Calcium can reverse neuromuscular blockade. Amphotericin B, additional neuromuscular blockers, and vancomycin are not indicated.

A patient who takes the loop diuretic ethacrynic acid is given intravenous gentamicin for an infection. After several days of treatment with gentamicin, the nurse reviews the patient's most recent laboratory results and notes a gentamicin trough of 2.1 mcg/mL and normal blood urea nitrogen (BUN) and serum creatinine levels. The nurse will question the patient about: a. gastrointestinal (GI) symptoms. b. headache, dizziness, or vertigo. c. presence of rash. d. urine output.

ANS: B Ethacrynic acid has ototoxic properties, and patients who take this drug with an aminoglycoside have an increased risk of ototoxicity, especially when trough levels of the aminoglycoside are elevated. A trough level of 2.1 mcg/mL is above normal limits for gentamicin, so this patient should be asked about early signs of ototoxicity. There is no indication to evaluate for GI symptoms, rash, or urine output.

A patient who has been taking gentamicin for 5 days reports a headache and dizziness. What will the nurse do? a. Request an order for a gentamicin peak level. b. Suspect ototoxicity and notify the prescriber. c. Tell the patient to ask for help with ambulation. d. Tell the patient to report any tinnitus.

ANS: B Headache and dizziness are signs of ototoxicity, and the prescriber should be notified. A peak level is not indicated; it is more important to know the trough level. Telling the patient to ask for help with ambulation and to report tinnitus should both be done but are not the priority nursing action.

A nurse is preparing to administer a dose of gentamicin to a patient who is receiving the drug 3 times daily. The nurse will monitor _____ levels. a. peak b. peak and trough c. serum drug d. trough

ANS: B When divided doses of aminoglycosides are given, it is important to measure both peak and trough levels of the drug, because it is more difficult to achieve therapeutic peaks in lower doses without causing toxicity. Trough levels are drawn when single-dosing regimens are used, because high peak levels are guaranteed.

A nurse is reviewing the culture results of a patient receiving an aminoglycoside. The report reveals an anaerobic organism as the cause of infection. What will the nurse do? a. Contact the provider to discuss an increased risk of aminoglycoside toxicity. b. Continue giving the aminoglycoside as ordered. c. Request an order for a different class of antibiotic. d. Suggest adding a penicillin to the patient's drug regimen.

ANS: C Aminoglycosides are not effective against anaerobic microbes, so another class of antibiotics is indicated. There is no associated increase in aminoglycoside toxicity with anaerobic infection. The aminoglycoside will not be effective, so continuing to administer this drug is not indicated. Adding another antibiotic is not useful, because the aminoglycoside is not necessary.

A patient shows signs and symptoms of conjunctivitis. Which aminoglycoside would the nurse expect to be ordered? a. Amikacin (Amikin) b. Kanamycin (Kantrex) c. Neomycin (Neomycin) d. Paromomycin (Humatin)

ANS: C Neomycin is used for topical treatment of infections of the eye, ear, and skin. Amikacin, kanamycin, and paromomycin are not topical treatments and are not indicated for eye infections.

A patient is receiving tobramycin 3 times daily. The provider has ordered a trough level with the 8:00 AM dose. The nurse will ensure that the level is drawn at what time? a. 4:00 AM b. 7:00 AM c. 7:45 AM d. 8:45 AM

ANS: C When a patient is receiving divided doses of an aminoglycoside, the trough level should be drawn just before the next dose; therefore, 7:45 AM would be the appropriate time. It would not be appropriate to draw a trough at the other times listed.

A nurse preparing to administer intravenous gentamicin to a patient notes that the dose is half the usual dose for an adult. The nurse suspects that this is because this patient has a history of: a. antibiotic resistance. b. interpatient variation. c. liver disease. d. renal disease.

ANS: D The aminoglycosides are eliminated primarily by the kidneys, so in patients with renal disease, doses should be reduced or the dosing interval should be increased to prevent toxicity. Patients with antibiotic resistance would be given amikacin. Interpatient variation may occur but cannot be known without knowing current drug levels. Aminoglycosides are not metabolized by the liver, so liver disease would not affect drug levels.

When administering an aminoglycoside to a patient with myasthenia gravis, it is most important for the nurse to assess what? A) Deep tendon reflexes B) Breath sounds C) Eyelid movement D) Muscle strength

B; Aminoglycosides can inhibit neuromuscular transmission, causing potentially fatal respiratory depression. Patients with myasthenia gravis (MG) are at an increased risk. Deep tendon reflexes, eyelid movement, and muscle strength are important assessments for a patient who has MG, but they are not as important as airway and breathing ability.

The nurse knows that there is an increased risk of ototoxicity in a patient receiving an aminoglycoside if which level is high? A) Concentration B) Trough C) Peak D) Dose

B; When trough levels remain elevated, aminoglycosides are unable to diffuse out of inner ear cells, thus exposing the cells to the medication for an extended time. Prolonged exposure (i.e., high trough levels), rather than brief exposure to high levels, underlies cellular injury.

A nurse monitors a patient who is receiving an aminoglycoside (gentamicin) for symptoms of vestibular damage. Which finding should the nurse expect the patient to have first? A) Unsteadiness B) Vertigo C) Headache D) Dizziness

C; Gentamicin causes irreversible ototoxicity, which results in both impaired hearing and disruption of balance. Headache is the first sign of impending vestibular damage (balance) and may last 1 to 2 days. Unsteadiness, vertigo, and dizziness appear after headache.

A patient who is receiving an aminoglycoside develops flaccid paralysis and impaired breathing. Which medication does the nurse anticipate administering? A) Magnesium sulfate (Epsom salt) B) Potassium chloride (K-Dur) C) Sodium bicarbonate (Citrocarbonate) D) Calcium gluconate (Kalcinate)

D; Flaccid paralysis and impaired breathing are signs of impaired neuromuscular transmission, which may occur with aminoglycosides, especially if they are administered concurrently with a neuromuscular blocking agent. Impaired transmission can be reversed with intravenous infusion of a calcium salt (calcium gluconate). Magnesium sulfate, potassium chloride, and sodium bicarbonate do not reverse impaired neuromuscular transmission caused by aminoglycosides.

Which enteral aminoglycoside would the nurse expect to be ordered preoperatively for a patient having intestinal surgery? A) Gentamicin B) Tobramycin C) Amikacin D) Neomycin

D; In general, aminoglycosides are poorly absorbed in the gastrointestinal (GI) tract. Neomycin is given orally to suppress bowel flora before surgery of the intestine and is not used parenterally because of its high nephrotoxicity and ototoxicity. Gentamicin, tobramycin, and amikacin are administered parenterally only.

A nurse is administering a daily dose of tobramycin at 1000. At which time should the nurse obtain the patient's blood sample to determine the trough level? A) 0800 B) 0900 C) 1130 D) 1200

The answer is B, Trough levels determine the lowest level between doses. Blood is drawn just before the next dose is administered when a divided dose is used or 1 hour before the next dose if a single daily dose is used.

A patient who is receiving an aminoglycoside (gentamicin) has a urinalysis result with all of these findings. Which finding should a nurse associate most clearly with an adverse effect of gentamicin? A) White blood cells (WBCs) B) Glucose C) Ketones D) Protein

The answer is D, Aminoglycoside-induced nephrotoxicity usually presents as acute tubular necrosis. Symptoms of concern are protein in the urine, dilute urine, and elevation of the serum creatinine and blood urea nitrogen (BUN) levels. WBCs, glucose, and ketones are not specifically related to gentamicin use.