Antibiotics and GI

An older client has been prescribed omeprazole for the treatment of gastroesophageal reflux disease (GERD). What explanation should the nurse provide when asked by the client why they are not being treated with famotidine?

"Proton pump inhibitors, like omeprazole, produce fewer adverse effects among the older population." explanation:Proton pump inhibitors like omeprazole may be the best choice for treating GERD in older patients because of fewer adverse effects and better therapeutic response with these drugs. Famotidine is a histamine-2 antagonists. The cost of the medication is not a primary factor in prescribing therapy for GERD. It is not standardly recommended to take omeprazole at bedtime.

A female client is currently taking sucralfate and has been given a prescription for ciprofloxacin for treatment of a urinary tract infection. The nurse will inform the client that she should take her medication in what way?

"Take the ciprofloxacin 2 hours before the sucralfate." explanation:It is important for the client to take the ciprofloxacin 2 hours prior to taking sucralfate to ensure full absorption of the ciprofloxacin.

when using the step up approach in caring for pts with GERD the step up from once daily ppi use is:

PPI (omeprazole) BID for 4 to 8 weeks

Non-systemic antacids

}Aluminum Hydroxide }Magnesium Hydroxide (diarrhea) }Calcium Carbonate (tums) }Al/Mg combinations

How do H2 receptor antagonists work?

}Competitively binds to H2 receptors on the parietal cell and decreases histamine stimulated gastric acid.

Systemic antacids

}Sodium Bicarbonate (Alka-Seltzer) ( we don't want this because it changes the urine and blood pH)

Recent concerns of PPI's

◦Increased risk of osteoporotic fractures - decreased calcium absorption ◦C. difficile - spores survive in alkalotic environment ◦HCAP - bacteria survive in alkalotic environment

How do antacids work?

◦Work by neutralizing acid, inhibiting pepsinogen to pepsin, and may bind bile salts

causes of PUD

-H. pylori - NSAIDs - Stress (physiological)

The nurse should administer which of the following medications cautiously to clients with vitamin B12 deficiency as the prolonged use of these drugs decreases the body's ability to absorb vitamin B12? Select all that apply:

- Rabeprazole (Aciphex)- Pantoprazole (Protonix) Explanation:The nurse should administer proton pump inhibitors, like rabeprazole (Aciphex) and pantoprazole (Protonix), cautiously to clients with vitamin B12 deficiency as the prolonged use of these drugs decreases the body's ability to absorb vitamin B12.

NSAIDs mechanisms of injury

- direct action on the mucosa - inhibition of prostaglandins (prostaglandins protect the GI tract and cause pain)

protective forces for PUD

- mucus secretion - bicarbonate secretion - mucosal blood flow - cell restitution - prostaglandins (responsible for majority of protective forces)

A nurse is teaching a client about his prescribed lansoprazole. The nurse instructs the client to take the drug at which time?

1 hour before eating explanation:Proton pump inhibitors such as lansoprazole should be swallowed whole at least 1 hour before eating. The proton pump inhibitors suppress gastric acid secretion by blocking the final step in the production of gastric acid by the gastric mucosa. After meals will inhibit suppression of gastric acid. On rising and at bedtime are not optimal times to take lansoprazole.

Henry is 82 years old and takes two aspirin every morning to treat the arthritis pain in his back. He states the aspirin helps him to "get going" each day. Lately he has had some heartburn from the aspirin. After ruling out an acute GI bleed, what would be an appropriate course of treatment for Henry? 1. Add an H2 blocker such as ranitidine to his therapy. 2. Discontinue the aspirin and switch him to Vicodin for the pain. 3. Decrease the aspirin dose to one tablet daily. 4. Have Henry take an antacid 15 minutes before taking the aspirin each day.

1. Add an H2 blocker such as ranitidine to his therapy.

how long does it take for PPI's to heal peptic ulcers?

4-6 weeks

Occasionally, a bismuth preparation is added to the treatment regimen for duodenal ulcers. What are bismuth's effects against H. pylori organisms.

A bismuth preparation is added to some regimens. Bismuth exerts antibacterial effects against H. pylori. It also increases secretion of mucus and bicarbonate, inhibits pepsin activity, and accumulates in ulcer craters.

A 42-year-old woman comes to the physician because of pain in her left ankle for 2 days. The pain is worse at night and with exercise. Five days ago, the patient was diagnosed with Salmonella gastroenteritis and started on ciprofloxacin. She has ulcerative colitis, hypertension, and hypercholesterolemia. She has smoked two packs of cigarettes daily for 25 years and drinks 2-3 beers daily. Current medications include mesalamine, hydrochlorothiazide, and simvastatin. She is 158 cm (5 ft 2 in) tall and weighs 74 kg (164 lb); BMI is 30 kg/m2. Her temperature is 36.7°C (98°F), pulse is 75/min, and blood pressure is 138/85 mm Hg. There is tenderness above the left posterior calcaneus and mild swelling. There is normal range of motion of the left ankle with both active and passive movement. Calf squeeze does not elicit plantar flexion. Which of the following is the most likely underlying mechanism for this patient's symptoms?

A. adverse medication effect Tendinopathy is a rare adverse effect of fluoroquinolone antibiotics (such as ciprofloxacin) and the mechanism is unknown. It usually occurs within the first 90 days of taking the medication and the Achilles tendon is the most commonly affected tendon. Symptoms include pain, swelling, and inflammation at the insertion site of the posterior calcaneus. In rare cases, tendon rupture can occur, as evidenced by the positive Thompson test in this patient. Fluoroquinolones should be immediately discontinued if tendinopathy or rupture is suspected.

A 56-year-old woman comes to the physician because of a 2-week history of fatigue and painless bruising over her arms and trunk. She has also had several episodes of nosebleeds that resolved with compression after a few minutes. She recently completed treatment for a urinary tract infection. She has had no changes in her weight. She has type 2 diabetes mellitus and hypertension. Her last menstrual cycle was 5 years ago. She does not smoke or drink alcohol. Home medications include metformin, amlodipine, and enalapril. Her vital signs are within normal limits. Physical examination shows pale conjunctivae. There are ecchymoses and petechiae over the upper extremities, chest, and back. There is no lymphadenopathy. The remainder of the physical examination is unremarkable. Laboratory studies show: -Hemoglobin= 8.7 -leukocyte count= 1100 -platelet count= 54,000 -reticulocyte count= 0.1% MCV= 93 which of the following is most likely to confirm the diagnosis?

A. bone marrow biopsy Pancytopenia is a possible adverse effect of sulfamethoxazole/trimethoprim (Bactrim) treatment, which this patient most likely received for her UTI. To confirm the diagnosis, a bone marrow biopsy should be conducted, which shows a decrease of all proliferating cell lines, although the residual hematopoietic cells maintain normal morphology. The stroma is replaced with fat cells, and there are no signs of fibrosis or infiltration of malignant cells.

An 84-year-old woman is brought by her caretaker to the physician because of a 2-day history of fever, severe headache, neck pain, and aversion to bright light. She appears uncomfortable. Her temperature is 38.5°C (101.3°F), pulse is 110/min, and blood pressure is 145/75 mm Hg. Physical examination shows involuntary flexion of the bilateral hips and knees with passive flexion of the neck. Cerebrospinal fluid analysis shows a leukocyte count of 1200/mm3 (76% segmented neutrophils, 24% lymphocytes), a protein concentration of 113 mg/dL, and a glucose concentration of 21 mg/dL. A CT scan of the brain shows leptomeningeal enhancement. Which of the following is the most appropriate initial pharmacotherapy?

A. ceftriazone, vancomycin, and ampicillin Third generation cephalosporins (e.g., cefotaxime, ceftriaxone) are broad-spectrum antibiotics that are effective against most gram-negative and gram-positive bacteria with the exception of Enterococcus and Listeria. Since L. monocytogenes is an important cause of bacterial meningitis in patients > 60 years, empiric antibiotic therapy in this group should include ampicillin, an anti-listerial antibiotic. Ampicillin would also provide coverage against gram-positive and gram-negative bacteria, but its spectrum of activity is not as broad as 3rd generation cephalosporins. Vancomycin, which acts only against gram-positive bacteria, should be included in the antibiotic regimen because the incidence of penicllin- and cephalosporin-resistant pneumococcal infection has increased in recent years. Vancomycin, while effective in Listeria bacteremia, is not very effective against CNS Listeria infections. Therefore, ampicillin should be used despite the addition of vancomycin to the regimen.

A 32-year-old man comes to the physician because of severe burning with urination for the past 3 days. During this period, he has had clear urethral discharge early in the morning. He has no history of serious illness, except for a rash following treatment with erythromycin 20 years ago. The patient takes no medications. He is sexually active with one male and one female partner; they use condoms inconsistently. His younger brother was diagnosed with Crohn disease at the age of 24 years. The patient does not smoke. He drinks one to two beers on weekends. He appears well. Temperature is 36.8°C (98°F), pulse is 75/min, and blood pressure is 135/78 mm Hg. Physical examination shows no abnormalities. Gram stain of a urethral swab shows neutrophils but no organisms. Which of the following is the most likely causal pathogen?

A. chlamydia trachomatis This patient does not use condoms consistently, which puts him at risk of acquiring sexually transmitted infections, such as Chlamydia trachomatis, the most common cause of nongonococcal urethritis. C. trachomatis is often asymptomatic, but may cause clear, urethral discharge, as in this patient. Chlamydia are intracellular organisms that are notoriously difficult to stain, which explains why neutrophils are seen (indicating bacterial infection) but no organisms. The typical screening test for chlamydia would be DNA amplification.

When describing the possible adverse effects associated with omeprazole therapy, which of the following would the nurse identify as least common?

Alopecia explanation:Alopecia can occur with proton pump therapy, but it is not a common adverse effect. Common adverse effects include dizziness, headache, and cough.

Gastroesophageal reflux disease (GERD) may be aggravated by the following medication that effects lower esophageal sphincter (LES) tone:

B. Estrogen

Nucleic acid amplification testing (NAAT) of first-void urine confirms infection with Chlamydia trachomatis. Treatment with the appropriate pharmacotherapy is started. Which of the following health maintenance recommendations is most appropriate at this time?

B. avoid sun exposure One common adverse effect of all tetracyclines, including doxycycline, is an increase in photosensitivity. The drug itself absorbs UV light and releases it to the surrounding tissue, causing damage in areas exposed to sun. Other adverse effects of tetracyclines include deposition in the bones and teeth through complex formation with calcium ions. If administered to children, this may impair growth and cause discoloration of the teeth.

Which adverse effect has not been associated with PPI's?

B12 deficiency

When using the step up approach in caring for pts with GERD, the step up from OTC antacid use is:

C. Histamine2 receptor antagonist (ranitidine) for 4 to 8 weeks

A 68-year-old man comes to the emergency department because of a cough, dyspnea, and fever for 1 day. The cough is productive of small amounts of green phlegm. He has metastatic colon cancer and has received three cycles of chemotherapy with 5-fluorouracil, leucovorin, and oxaliplatin; his last chemotherapy session was 2.5 months ago. He has chronic obstructive pulmonary disease and has been treated with antibiotics and prednisolone for acute exacerbations three times in the past year. His medications include a fluticasone-salmeterol inhaler and a tiotropium bromide inhaler. He has smoked one pack of cigarettes daily for 48 years. His temperature is 39.1°C (103.1°F), pulse is 112/min, respirations are 32/min, and blood pressure is 88/69 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 88%. Pulmonary examination shows diffuse crackles and rhonchi. An x-ray of the chest shows a left upper-lobe infiltrate of the lung. Two sets of blood cultures are obtained. Endotracheal aspirate Gram stain shows gram-negative rods. Two large bore cannulas are inserted and intravenous fluids are administered. Which of the following is the most appropriate pharmacotherapy?

C. cefepime and levofloxacin Cefepime and levofloxacin are the first-line treatment for patients with CAP in whom there is a high suspicion of P. aeruginosa infection. Other treatment options for CAP with P. aeruginosa include piperacillin/tazobactam, meropenem, or imipenem plus a fluoroquinolone. An aminoglycoside may be added as well.

You know that penicillins are more effective when used on what type of bacteria?

Gram-positive bacteria

Metoclopramide improves GERD symptoms by:

Increasing lower esophageal tone

non-pharmacological therapy for PUD

Remove risk factors ◦stop smoking ◦make dietary changes ◦decrease/stop caffeine and alcohol consumption ◦Minimize or eliminate NSAID and aspirin use

Which of the following does not tell you if H. pylori is cured?

Serology

A nurse is caring for a patient who has a serious infection. The patient is being treated with combination therapy of a cefazolin and an aminoglycoside. The nurse will be sure to monitor which of the following?

Serum BUN and creatinine

The nurse is caring for a 23-year-old female client who uses oral contraceptives and has been prescribed ampicillin for treatment of a respiratory infection. What information is most important for the nurse to share with this client?

Use a type of barrier birth control while you are taking this antibiotic.

Omeprazole (Prilosec) may be used with what antibiotic in some H. pylori eradication regimens?

amoxicillin explanation:The gastric acid pump or proton pump inhibitors are recommended for the short-term treatment of active duodenal ulcers, GERD, erosive esophagitis, and benign active gastric ulcer; for the long-term treatment of pathological hypersecretory conditions; as maintenance therapy for healing of erosive esophagitis and ulcers; and in combination with amoxicillin and clarithromycin for the treatment of H. pylori infection. Options A, B, and C are not antibiotics used to eradicate H. pylori.

How do PPI's work?

block gastric acid secretion by inhibiting gastric H/K ATPase in the gastric parietal cell

Because of the possible adverse effects of long-term proton pump inhibitor (PPI) use, the nurse practitioner should focus on what assessment in a 72-year-old client?

bone density explanation:Long-term use of PPIs is associated with increased risk of hip fractures in people older than 50 years of age; the risk of fractures increases the longer the medications are taken and is greater in people who take higher dosages of PPIs. Bone density assessment may thus be warranted. None of the other options are associated with this class of medications.

Beta-lactam antibiotics, such as penicillins and cephalosporins, fight infection by inhibiting development of the causative bacteria. What specific component development do these drugs affect?

cell wall synthesis

The nurse should warn a client taking aluminum- and calcium-containing antacids about which adverse effects?

constipation

Are duodenal or gastric ulcers more common?

duodenal ulcers are 4x more common

Best way to prevent the drug interaction of H2 blockers and PPI's with iron?

give higher doses of iron (ex. take 3 times a day vs 2 times a day)

H. pylori: gram negative or gram positive

gram negative bacilli

When comparing the H2RAs to each other, you would find that cimetidine (Tagamet) is more likely to cause which adverse effect?

gynecomastia

The nurse should be aware that the combination of omeprazole and warfarin creates a risk of what adverse reaction?

hemorrhage explanation:Omeprazole increases blood levels of the anticoagulant warfarin thus creating a risk for bleeding. Such an elevation in warfarin would not increase the risk for the development of any of the other options.

Ranitidine and cimetidine are both H2RAs used in the treatment of peptic ulcer disease. Of the two, ranitidine is preferred in critically ill clients because it is less likely to:

interfere with the metabolism of other drugs. explanation:Unlike cimetidine, ranitidine does not affect the cytochrome P450 drug-metabolizing system in the liver and therefore does not interfere with the metabolism of other drugs by that system.

An older adult is to receive a low dose of a cephalosporin for an infection. When realizing that this client has age-related diminished renal function, what intervention should the nurse implement?

monitor blood creatinine levels

A young adult has been receiving Keflex P.O. for the last 5 days to treat a respiratory infection. The nurse is concerned when the client reports urinating only once in the last 16 hours. What should the nurse consider as the cause?

nephrotoxicity

IgG antibodies

once positive always positive

The nurse knows that superinfections are a concern for clients who have been taking oral penicillins. Which is one of the more common superinfections?

pseudomembranous colitis

Ranitidine (Zantac) should be cautiously administered to individuals with evidence of which of the following conditions?

renal disease Explanation:All of the H2RAs are eliminated through the kidneys, and dosages need to be reduced in clients with renal impairment. There is no caution necessary with Zantac and people with diabetes, pulmonary disease, or migraine headaches.

A health care center is conducting a seminar on cephalosporins drugs. During the question-and-answer period, the audience wants examples of conditions that can be treated by cephalosporins. Which of the following infections should the nurse state as examples?

urinary tract infections

goal of treatment of PUD

to relieve pain, accelerate healing, minimize recurrence and prevent complications (bleeding, perforations, and obstructions)

The use of calcium carbonate is associated with the development of acid rebound. True or False.

true

H pylori produces _____ that allows it to survive at low pH

urease