NUR 340 Exam 3
A patient is receiving a single daily dose of IV tobramycin which is given over 30 minutes. If the drug is to be administered at 1000, when will the nurse obtain a blood sample for determination of a trough level? 1200 0930 1030 0900
0900 Rationale: Samples for trough levels should be drawn 1 hour before the next IV dose when a single daily dose is used. Peak levels are drawn 30 minutes after the dose is administered. See Lehne p. 1056
What are some acute interventions for osteomyelitis?
Handle involved limb carefully...excessive movement can lead to pathologic fx Avoid exercises and heat application Increases circulation and edema → Spread of infection Handle dressings carefully to avoid cross-contamination Elevated limb can cause flexion contracture, leading to foot drop if foot not kept in neutral position
What are the goals of the treatment of pneumonia?
Have adequate rate, rhythm, and depth of respirations Lungs clear to auscultation Free of signs and symptoms of infection O2 sat > 92%
What generation of cephalosporins are preferred?
Third generation Preferred therapy More active against gram negative aerobes
What is medical care-association pneumonia?
Three forms of MCAP -Hospital-Acquired Pneumonia (HAP) Occurs 48+ hours after hospital admission No signs or symptoms present on admission -Ventilator-Associated Pneumonia (VAP) Occurs 48+ hours after endotracheal intubation -Health Care-Associated Pneumonia (HCAP) New onset pneumonia in a patient: Hospitalized in an acute care hospital for 2+ days or longer within 90 days of infection Resided in long-term care facility Received IV antibiotics, chemo, or wound care within 30 days prior to infection Attended a hospital or hemodialysis clinic.
How is prostatitis treated?
Treated with antibiotics over weeks or months Poor penetration of antibiotics into prostate tissue Comfort measures sitz baths muscle relaxants NSAIDs stool softeners alpha-adrenergic blockers to relax muscle tissue in prostate Avoid bladder irritants Avoid decongestants or antihistamines can cause urinary retention
What are the types of penicillin allergies?
Types of reactions -Immediate (reaction in 2 to 30 minutes) Laryngeal edema, bronchoconstriction, severe hypotension -Accelerated (reaction in 1 to 72 hours) -Late (reaction takes days or weeks to develop) Treatment Epinephrine Respiratory support
How can patients prevent herpes zoster?
Vaccination for herpes zoster (shingles) Per CDC: All adults 60 years and older Reduces risk of shingles by about half Reduces risk of post-herpetic neuralgia by 67% Most effective in 60-69 year old group, but some protection in older groups Effective for at least 6 years, but may last longer Reimbursement: may not be fully covered even with Medicare
What are the clinical manifestations of UTIs in older adults?
Vague, usual symptoms frequently absent Increasing confusion Frequent, unexplained falls Sudden onset or worsening urinary incontinence Loss of appetite Non-localized abdominal pain rather than dysuria and suprapubic pain
What is the preferred antimicrobial used to treat abscess/cellulitis?
Vancomycin
narrow spectrum and bactericidal; excreted by kidneys-nephrotoxic and can be ototoxic; therefore will need to monitor peaks and troughs per orders; safe alternative if PCN allergy; appropriate for treatment of MRSA; if metronidazole ineffective, this drug may be used po to treat cdiff; if infused too quickly you are putting your patient at risk for red man syndrome
Vancomycin
What are some examples of emerging infections?
West Nile virus - carried and transmitted by mosquitoes Influenza virus - Influenza A spreads from animals to humans, then humans to humans Droplet transmission Swine flu (H1N1) spread internationally in 2009 Avian flu (H5N1) current risk for commercial poultry Ebola virus - Great News from the WHO!! New vaccine has been found to be highly effective in phase III trials in Guinea Contact transmission
How do you react if a patient states that they have a penicillin allergy?
What is their reaction like Assess for penicillin allergy in each patient who will be receiving penicillin If history of mild reaction - consider cephalosporin If history of anaphylaxis - avoid administration of penicillin or cephalosporins Safe alternatives - vancomycin, erythromycin, clindamycin
What is a adverse infusion reaction of amphotericin B?
Fever, chills, rigors, nausea, and headache Caused by release of proinflammatory cytokines Symptoms begin 1-3 hours after start of infusion and last for about 1 hour Less intense with lipid-based ampho B formulations Mild reactions: pretreatment options Diphenhydramine plus acetaminophen Aspirin can help but may increase renal damage IV meperidine or dantrolene can be given if rigors occur Hydrocortisone can be given with caution
if your patient develops candidiasis during their antibiotic course, this drug may be ordered to treat it; this drug is safer to use for systemic fungal infections than Amphotericin B. It can be given IV or po.
Fluconazole:
What is Ciprofloxacin (Cipro)?
Fluoroquinolone orally or IV Broad-spectrum agents with multiple applications Drug of choice for anthrax (bid for 60 days) Infections: respiratory, UTI, GI, bones, joints, skin, and soft tissue
What are the food and drug interactions of ciprofloxacin (Cipro)?
Food and drug interactions Aluminum or magnesium-containing antacids Sucralfate Milk/dairy products Administer 6 hours before or 2 hours after fluoroquinolone Elevation of drug levels *Warfarin* - Adjust doses based on drug levels or PT time
bactericidal ad narrow spectrum; Must report any change in hearing/ringing of the ears as hearing loss is an irreversible adverse effect; Must monitor BUN/Cr, Creatinine Clearance as it is a nephrotoxic drug; for these reasons, it will be necessary to monitor peaks and troughs; it is an Aminoglycoside
Gentamicin
What are the respiratory defense mechanisms?
Air filtration Epiglottis closure over trachea Cough reflex Mucociliary escalator mechanism Reflex bronchoconstriction Immunoglobulins A & G Alveolar macrophages
What are some additional treatment options for osteomyelitis?
-Wound vacs Intermittent/constant irrigation of affected bone with abx -Antibiotic-impregnated polymethyl methacrylate bead chains implanted to help combat infection at source -Casts or braces to protect surgical site -Orthopedic prosthetic in case of amputation -PT/OT
How does amphotericin B cause hypokalemia?
-Results from damage to the kidneys -Potassium supplements may be needed -Monitor serum levels
What are the first line antibiotics used for UTIs?
-Trimethoprim/sulfamethoxazole (TMP/SMX) Used to treat uncomplicated or initial UTI Inexpensive Taken twice a day E. coli resistance to TMP-SMX ↑ -Nitrofurantoin (urinary tract antiseptic) Dosed tid/qid or longer-acting formulation dosed bid
A patient who works as a landscaper is preparing to be discharged home. Ciprofloxacin (Cipro) has been prescribed for outpatient therapy. Which of the following will the nurse include in the discharge teaching for this patient? "You may take the medication with milk of magnesia." "Use sunscreen and protective clothing when outdoors." "Take the medication with crackers and cheese." "Take the medication until all symptoms subside."
"Use sunscreen and protective clothing when outdoors." Rationale: The patient, a landscaper, should be advised to wear sunscreen and protective clothing when outdoors, because the medication may cause phototoxicity. The medication should be taken until it is gone, not just until the patient's symptoms are improved. Absorption of fluoroquinolones is reduced when taken with a number of products including aluminum or magnesium containing antacids and milk or other dairy products. See Lehne p. 1087
What is herpes zoster?
(Shingles) Infection caused by reactivation of varicella zoster virus in people who have had chickenpox Seen most frequently in older adults Dormant virus resides in dorsal root ganglia of sensory nerves Unilateral linear distribution of grouped vesicles and pustules along a dermatome Found on trunk, face, and lumbosacral areas Mild to severe pain Potentially contagious to those not previously exposed to virus or have not been vaccinated against chickenpox
What antibiotics are used for osteomyelitis?
-Aminoglycosides Tobramycin, Neomycin, Gentamicin Hearing loss, nephrotoxicity, & neurotoxicity -Cephalosporins Cefazolin Hives, severe or watery stools, hemoccult, throat/mouth sores -Fluoroquinolones Ciprofloxacin, Levofloxacin Tendon rupture Peak and trough levels should be monitored during therapy to avoid adverse effects/toxicity
How to prevent antimicrobial resistance?
-Appropriate infection control measures including hand hygiene -Use antibiotics only when necessary; avoid use if not necessary. -Use vancomycin only when necessary -Prevent contamination of culture samples -Choose drugs that are effective against the causative organism -Treat only active infections, not colonization -Use catheters only if necessary and remove as soon as possible. -Encourage vaccination to reduce need for antimicrobial therapy
What are the routes of infection in pneumonia?
-Aspiration Normal flora from nasopharynx or oropharynx -Inhalation Microbes present in air -Hematogenous spread Primary infection elsewhere in the body
Information about Penicillins
-Beta lactam family Bactericidal Weaken cell wall of microbe -Administration IM or IV -Distribution Well-distributed to most tissues except meninges, joints, & eyes Inflammation enhances absorption in meninges, etc. -Metabolism & Excretion Eliminated by kidneys Reduce dosage if renal impairment Monitor kidney function for high risk of toxicity -Adverse reactions One of "safest" drugs Primary adverse reaction - allergic response
What are azoles?
-Broad-spectrum antifungal drugs -Alternative to ampho B for most systemic mycoses -Lower toxicity -Can be given orally Disadvantage Inhibit P450 drug-metabolizing enzymes and can increase the levels of many other drugs
How do you monitor the effectiveness of antibiotics?
-Clinical responses Reduction of fever Improvement of symptoms associated with affected system -Laboratory results Serum drug levels White blood cell counts Cultures
What are cephalosporins?
-Most widely used group of antibiotics -Beta-lactam antibiotics -Similar to penicillin structure -Bactericidal -Broad spectrum -Usually given parenterally -Toxicity is low
What are the complications of osteomyelitis?
-Osteonecrosis -Amputation of affected limb -Sepsis -Additional Wounds -Adverse/Toxic Reactions to prolonged and high-dose antibiotic therapy -Impaired growth in children
What are the adverse effects of vancomycin?
-Ototoxicity (reversible or permanent) -Red man syndrome Release of histamine leading to flushing, pruritus, urticaria, tachycardia, & hypotension To prevent: administer over at least 60 minutes -Thrombophlebitis (common) -Thrombocytopenia (rare) -Allergic reaction
What are some urinary analgesics used for UTIs?
-Phenazopyridine Used in combination with antibiotics Provides soothing effect on urinary tract mucosa Stains urine reddish orange Can be mistaken for blood and may stain underclothing -Methenamine/phenyl salicylate Used in combination with antibiotics Used to relieve UTI symptoms Preparations with methylene blue tint urine blue or green
What are the clinical manifestations of Acute bacterial prostatitis?
Fever, chills Back pain Perineal pain Acute urinary symptoms: frequency, urgency, cloudy urine May have acute urinary retention from prostatic swelling
What are the side effects of cefotetan (Cefotan)?
Interferes with vitamin K metabolism and can cause subsequent bleeding Can cause alcohol intolerance symptoms similar to disulfiram (Anatbuse)
What are some drug to drug interactions with penicillin?
Aminoglycosides (gentamicin) -High concentrations of penicillin interact with aminoglycosides and inactivate them. -Administer separately, never in same IV solution Probenecid (used for gout) -Slows renal excretion of penicillin Problem if renal impairment present
What cephalosporin drug is eliminated through the liver?
3rd generation ceftriaxone (Rocephin) Dosage reduction not necessary for renal insufficiency
What drug is used for systemic fungal infections? It is broad spectrum. It has significant adverse effects and other antifungals (azoles) can be an alternative. Some degree of toxicity to kidneys can result from this drug. A common infusion reaction is fever, chills, rigors, nausea, headache ....these usually appear within 1-3 hours of administration and can last approximately an hour.
Amphotericin B
What is pneumonia?
An acute infection of the lung parenchyma Leading cause of death in the U.S. until 1936 Sulfa drugs and penicillin pivotal in treatment of pneumonia Continues to have significant morbidity and mortality rates Community-acquired pneumonia = 6th leading cause of death in people 65+ yoa in the U.S.
What is a UTI?
Acute local inflammatory condition caused by infection Can spread to become systemic infection Most common bacterial infection in women Acute cystitis rare in men At least 20% of women will develop a UTI during their lifetime Bladder and its contents are free of bacteria in majority of healthy persons Minority of healthy individuals have colonizing bacteria in bladder Called asymptomatic bacteriuria and does not justify treatment
What are some guideline-based indicators for indwelling urinary catheters?
Acute urinary retention or bladder outlet obstruction Need for accurate measurements of output in critically ill patients Urologic surgery Prolonged duration of surgery Large volume diuretics during surgery Assist in healing of sacral or perineal wounds in incontinent patients Prolonged immobilization required
What is acquired resistance?
All antimicrobials have potential to promote development of resistant microbes. Broad spectrum antimicrobials have greatest potential because they kill many competing microbes -Leave drug-resistant microbes without check and balance system -Kill normal flora as well as infectious agent. Narrow spectrum antibiotics have less potential Are effective against only a few microbes
What is acute osteomyelitis?
All initial infections Infections of less than 1 month in duration
What are candidiasis infections?
Also known as a yeast infection Caused by Candida albicans 50% of adults are symptom-free carriers Found in mouth/throat/esophagus as white, cheesy plaque resembling curdled milk Called thrush or oral candidiasis Found in vagina: pruritus, dysuria, red edematous vaginal wall with white patches Skin: diffuse papular erythematous rash with pinpoint satellite lesions around the edges of affected area
What are the cephalosporin pharmacokinetics?
Administration/Absorption Limited number by po; may take with food More commonly by IM or IV Only cefuroxime available by oral (Ceftin) & parenteral (Zinacef)routes Distribution Well-distributed to most tissue Exceptions: Ocular fluid CSF for 1st & 2nd generation Elimination Renal Reduce dosage for renal insufficiency to prevent toxic accumulation Hepatic Only one - 3rd generation ceftriaxone (Rocephin) Dosage reduction not necessary for renal insufficiency
What are the adverse effects of Ketoconazole (Formerly Nizoral)?
Adverse effects (generally well tolerated) GI (can be reduced if given with food) Hepatotoxicity Rare but potentially fatal hepatic necrosis Effect on sex hormones Can inhibit steroid synthesis in humans Other adverse effects Rash, itching, dizziness, fever, chills, constipation, diarrhea, photophobia, and headache
What are the adverse effects of amphotericin B?
Adverse effects: -Infusion reactions -Nephrotoxicity -Hypokalemia -Bone marrow suppression
What are the risk factors for pneumonia?
Abdominal or thoracic surgery Age > 65 yoa Altered consciousness Bedrest or prolonged immobility Chronic illnesses Immunosuppressive disease and/or therapy Intestinal or gastric feedings (tube feedings) Smoking Tracheal intubation URIs
A patient is prescribed azithromycin. The patient previously experienced nausea and vomiting when taking erythromycin and wants to know whether to expect the same effects with azithromycin. How will the nurse respond? "Take the drug with a hearty meal to reduce gastrointestinal side effects." "I need to call your health care provider and ask for a different antibiotic." "I will get a prescription for an antiemetic in case this drug causes vomiting." "This drug is like erythromycin but has less severe gastrointestinal side effects."
Answer: "This drug is like erythromycin but has less severe gastrointestinal side effects." Rationale: The nurse's best response is that azithromycin has fewer severe gastrointestinal (GI) side effects than erythromycin. Calling the health care provider is not necessary because it is not known whether the patient will have any GI side effects; they occur in only 3 - 5% of those who take the drug. Obtaining a prescription for an antiemetic is not necessary. Azithromycin may be taken with or without food. The patient may take the medication with food to reduce GI side effects, but a large meal is not necessary to achieve this effect. See Lehne p. 1042
The nurse is caring for a patient who receives a divided dose of IV amikacin (Amikin) twice a day. When will the nurse draw blood for measurement of a trough aminoglycoside level? A.) just prior to administration of the next dose. B.) 1 hour before the next dose. C.) 30 minutes after the IV infusion is complete. D.) 1 hour after the IV infusion is complete.
Answer: A Rationale: When divided daily doses are prescribed, blood samples for measurement of trough levels are drawn immediately before administration of the next dose. This is the time at which the blood levels of the drug are at the lowest. To obtain peak levels, the nurse will draw a blood sample 30 after infusion the infusion is complete when the most drug is in the patient's bloodstream. See Lehne pp. 1056
A patient complains of mouth sores during antibiotic therapy. Upon assessment, the nurse notes white, patchy spots and redness of the tongue and throat. Which of the following medications could be used to treat this condition? (Select all that apply.) A.) clotrimazole troche B.) fluconazole (Diflucan) C.) bacitracin D.) nystatin (Mycostatin)
Answer: A, B, D Rationale: Fluconazole, nystatin and clotrimazole are antifungal agents that may be used to treat candidiasis of the mouth and esophagus. Bacitracin is an antibiotic ointment used for topical treatment of bacterial infections of the skin. See Lehne Table 92-5, and pp. 1100-1102.
Which of the following would be classified as a suprainfection? A.) peritonitis that developed after surgery for a ruptured appendix B.) monilial vaginal infection that developed during antibiotic therapy C.) pneumonia in a patient with chronic obstructive pulmonary disease D.) varicella outbreak after injection with varicella vaccine
Answer: B Rationale: "A suprainfection is defined as a new infection that appears during the course of treatment for a primary infection." Normal flora are inhibited by the antibiotic which then allows a secondary infectious agent to thrive.
A student nurse prepares to administer itraconazole (Sporanox) to a patient. Which of the following statements is most accurate about this drug? "Itraconazole is A.) effective against more fungi than amphotericin B." B. ) an inhibitor of drug-metabolizing enzymes in the liver." C.) toxic to the kidneys, central nervous system and liver." D.) always administered intravenously (IV) rather than by mouth."
Answer: B Rationale: Itraconazole inhibits hepatic enzymes that metabolize other drugs. This results in increased blood levels of these drugs. Therefore, concurrent use of itraconazole with drugs that affect heart rhythms is contraindicated. Itraconazole is administered by mouth rather than IV and may be used in place of amphotericin B for some types of fungal infections. Although itraconazole can cause liver damage, it is not nephrotoxic and does not cause toxicity in the central nervous system.
A 68-year-old patient is receiving an IV aminoglycoside for a serious infection. The patient develops heart failure and needs a diuretic. Which medication order would cause the nurse the most concern? A.) hydrocholothiazide (HCTZ) B.) ethacrynic acid (Edecrin) C.) furosemide (Lasix) D.) bumetanide (Bumex)
Answer: B Rationale: The risk of injury to the inner ear is significantly increased by concurrent use of an aminoglycoside and ethacrynic acid, both of which have ototoxic actions. Hydrochlorothiazide is not known to have a drug-to-drug interaction with aminoglycosides. Combining an aminoglycoside with other diuretics such as furosemide or bumetanide does not appear to cause any greater risk for ototoxicity than by administering the aminoglycoside by itself. See Lehne pg. 1052
The nurse administers ceftriaxone to a patient who also is taking warfarin. The nurse will monitor the patient carefully for which problem? bruising or bleeding gums hyperkalemia increased neutrophil counts elevated levels of ceftriaxone
Answer: Bruising or bleeding gums Rationale: The nurse should monitor the patient for bruising or bleeding gums, because ceftriaxone can promote bleeding, especially when administered concurrently with warfarin. The combination of these 2 drugs does not alter the effectiveness of the antibiotic; monitoring neutrophils will provide information only about the stage of the infection. Monitoring ceftriaxone levels provides information about whether the drug levels are sufficient to address the infection. Neither drug impacts the patient's potassium levels. See Lehne p. 1027
A patient who is receiving penicillin begins to wheeze and reports a feeling of impending doom. Upon assessing the patient, the nurse finds a blood pressure of 88/47 mm Hg. and a weak pulse of 120 beats per minute. Which order will the nurse implement first? A.) administer 500 mL IV fluid bolus B.) apply oxygen at 3L per nasal cannula C.) administer epinephrine D.) obtain an oropharyngeal airway device
Answer: C Rationale: The priority is to reverse the allergic reaction. This can be done by administering epinephrine, which is used to treat anaphylaxis (which the patient is manifesting). If the reaction is not reversed, an airway may be necessary. Oxygen is applied after the epinephrine is administered or a second nurse may apply the oxygen as the epinephrine is being given. IV fluids may be a consideration if the blood pressure does not rise after administration of epinephrine, but epinephrine is the priority. See Lehne, p. 1020
A hospitalized patient is receiving gentamicin (Garamycin) 80 mg IV twice daily for acute osteomyelitis. Which data about the patient is most important for the nurse to obtain before administering the gentamicin? a.) oral temperature b.) reports of nausea c.) BUN and creatinine levels d.) when an antacid was administered
Answer: C Rationale: Although the patient's temperature will be monitored on a regular basis in the hospital, gentamicin is nephrotoxic and can cause renal failure. Therefore monitoring renal function is critical. Nausea is not a common side effect of IV gentamicin. Because the drug is administered IV, an antacid will not affect absorption of the gentamicin.
A nurse transcribes a new prescription for potassium penicillin G given intravenously (IV) q 8 hours and gentamicin IV q 12 hours. Which plan is the best schedule for administering these drugs? a.) penicillin at 0800, 1600, and 2400; gentamicin at 1200 and 2400 b.) penicillin at 0600, 1400, and 2200; gentamicin at 0600 and 1800 c.) penicillin at 0800, 1600, and 2400; gentamicin at 0600 and 1800 d.) penicillin at 0100, 0900, and 1700; gentamicin at 0900 and 1800
Answer: C Rationale: Gentamicin should never be administered concurrently with penicillin, because they will interact, and the penicillin may inactivate the aminoglycoside. All options except A show concurrent administration. See Lehne p. 1064
The nurse is reviewing a patient's test results before administering the next dose of amphotericin B. The nurse's priority is to review which one of the following tests? A.) blood cultures B.) serum sodium levels C.) liver function tests D.) serum creatinine levels
Answer: D Rationale: Amphotericin B is highly nephrotoxic and some degree of renal impairment occurs in almost all patients who receive this drug. Therefore, it is of vital importance to closely monitor renal function in patients who are receiving amphotericin B. The dosage of the drug may need to be reduced. Blood cultures, if ordered, would have been drawn before the initial dose. Potassium levels, not sodium levels, should be monitored secondary to renal damage. Liver failure is a rare adverse effect. See Lehne pg 1094.
The nurse is providing education about tetracycline. Which patient statement confirms that the patient understood the teaching? "I will A.) expect a slight, acnelike rash with this medication." B.) take my antibiotic with my calcium supplements." C.) follow my antibiotic with an antacid." D.) not take my medication with dairy products."
Answer: D Rationale: A food-drug interaction occurs between dairy products and tetracycline. If the patient states that he or she will not take tetracycline with dairy products, the patient understands this food-drug interaction. A drug-drug interaction will occur with calcium-based supplements and magnesium or aluminum-based antacids and tetracycline. These products will produce chelation, a process by which these products bind with tetracycline and render it ineffective. The patient should take the tetracycline 1 hour before or 2 hours after ingesting any dairy foods or drugs with calcium, iron, magnesium, aluminum or zinc. An acnelike reaction would indicate an unexpected allergic response. See Lehne p. 1039
The nurse notifies the health care provider that a patient who is concurrently taking ciprofloxacin and warfarin. What change to the patient's medication dosages does the nurse anticipate? A.) increase in the ciprofloxacin dose. B.) decrease in the ciprofloxacin dose. C.) increase in the warfarin dose. D.) decrease in the warfarin dose.
Answer: D Rationale: Ciprofloxacin can elevate levels of warfarin in the blood which will cause more warfarin to be available and will thereby further decrease the patient's ability to clot. Decreasing the warfarin dosage while the patient is on ciprofloxacin will help keep the patient's clotting time within therapeutic range. The prothrombin time and INR level should be monitored, and the dosage of warfarin should be reduced as indicated. See Lehne p. 1087
A patient is prescribed both erythromycin and warfarin. It is important for the nurse to monitor which of the following laboratory tests? INR Hgb/Hct RBC BUN
Answer: INR Rationale: Erythromycin can affect plasma levels of warfarin which will change the patient's ability to clot. Increased plasma levels would mean more warfarin in the bloodstream and a decreased ability to clot. The patient's ability to clot should be monitored with an INR. See Lehne pg 1087.
The nurse on a medical-surgical unit is caring for a patient experiencing fever of unknown origin. The prescriber has ordered a broad-spectrum antibiotic. Which intervention is the nurse's priority? Delay administration of the antibiotic until culture results are available. Administer an antipyretic as soon as possible. Obtain all cultures before the antibiotic is administered. Administer the antibiotic as soon as it is available.
Answer: Obtain all cultures before the antibiotic is administered Rationale: It is essential that samples of exudates and body fluids (in this case, blood cultures) be obtained for culture prior to initiation of treatment. Administration of the antibiotic is important, but not more important than obtaining specimens for culture. Antipyretics may be indicated, but the priority is obtaining specimens for culture. Treatment may be initiated before the test results are available.
A patient has acquired hospital-associated MRSA. Which drug does the nurse anticipate will be ordered to treat this infection? vancomycin (Vancocin) TMP/SMZ (Bactrim) imipenem (Primaxin) azithromycin (Zithromax)
Answer: Vancomycin Rationale: MRSA is resistant to all penicillins and cephalosporins. These include beta lactam antibiotics such as imipenem. Most strains of MRSA are also resistant to many other antibiotics. The drug of choice is vancomycin although there are others that may be used. TMP/SMZ is a preferred drug for community-acquired MRSA. Azithromycin is a macrolide used for respiratory and skin infections as well as other infections such as mycobacterium avium and chlamydia.
A nurse is preparing to administer the antibiotic for a hospitalized patient who acquired a Methicillin-resistant Staph. aureus (MRSA) infection. Based on the nurses' knowledge of antibiotics for the treatment of MRSA, which medication may be ordered? Vancomycin Neomycin Cefazolin Ceftaroline Metronidazole Piperacillin
Answer: Vancomycin and ceftaroline Rationale: Methicillin-resistant Staph. aureus(MRSA), highly resistant bacteria, are resistant to all penicillins and all cephalosporins. Because most strains of MRSA are multidrug resistant, many other antibiotics are ineffective, including tetracyclines, clindamycin, trimethoprim/sulfamethoxazole, and beta-lactam agents (except ceftaroline). Preferred drugs are IV vancomycin, linezolid [Zyvox], daptomycin [Cubicin], telavancin [Vibativ], clindamycin, and ceftaroline. See Lehne p. 1017
A patient who has been receiving tetracycline develops watery profuse diarrhea. A stool specimen identifies the causative agent as Clostridium difficile. The nurse anticipates that the tetracycline will be discontinued and the patient started on which medication? erythromycin 500 mg po every 6 hours for 14 days. gentamicin 1 gm/kg every 8 hours IV in 100 mL 0.9 sodium chloride for 5 days. metronidazole (Flagyl) 500 mg po three times a day for 10 days. TMP/SMZ (Bactrim, Septra) 160 mg/800 mg po every 12 hours for 5 days
Answer: metroidazole Rationale: Metronidazole is the drug of choice for antibiotic associated colitis caused by Clostridium difficile. Adverse effects of gentamicin, an aminoglycoside, are typically related to ototoxicity and renal toxicity. Erythromycin can eliminate intestinal flora which can lead to suprainfection with such organisms as C. diff. TMP/SMZ is generally well-tolerated; serious adverse effects are rare and do not include colitis with associated diarrhea. See Lehne, p. 1031
The nurse is caring for an older adult patient with Crohn's disease. The patient has been taking metronidazole (Flagyl) for 6 months. The patient begins to complain of numbness and tingling in the lower extremities. The nurse should suspect extrapyramidal symptoms. peripheral neuropathy. myalgia. myopathy.
Answer: peripheral neuropathy Rationale: The patient's symptoms correlate with peripheral neuropathy, which is a risk of long-term treatment with metronidazole. The patient's symptoms do not describe myopathy (muscle weakness), myalgia (muscle pain), or extrapyramidal symptoms (drug-induced parkinsonism). See Lehne p. 1197
A patient with an infection caused Pseudomonas aeruginosa is being treated with an aminoglycoside. Which of the following findings would most concern the nurse? decreased white blood cell count proteinuria decreased serum creatinine concentrated urine
Answer: proteninuria Rationale: Aminoglycoside-induced nephrotoxicity usually manifests as acute tubular necrosis. Prominent symptoms are proteinuria, casts in the urine, production of dilute urine, and elevations in the serum creatinine and BUN. Resolution of infection results in a decrease in the white blood cell count.
A patient with osteomyelitis has been admitted to the nursing unit. Which of the following medications would the nurse expect to administer specifically to treat this condition? TMP/SMZ (Bactrim) nystatin (Mycostatin) abatacept (Orencia) tobramycin
Answer: tobramycin Rationale: Tobramycin, like gentamicin, is an aminoglycoside type of antibiotic that is often effective in the treatment of osteomyelitis. Abatacept is a biologic DMARD used to reduce inflammation in chronic inflammatory diseases. Nystatin is classified as a polyene antibiotic and is used only to treat candidiasis. TMP/SMZ (Bactrim or Septra) is a fixed-dose combination of a sulfonamide and trimethoprim which is used for UTI, otitis media, and infections of the respiratory tract.
How do we treat a fever caused by an infection?
Antibiotics: remember that antibiotics will be priority because if we treat the infection, it will help treat the fever Antipyretics as indicated
this drug is broad spectrum and bacteriostatic; it is eliminated by the liver; if the patient takes warfarin, you will need to closely monitor the PT/INR as pt. may potentially need a lower dose of warfarin during treatment; it is a macrolide
Azithromycin
What is Fluconazole (Diflucan)?
Azole group of antifungal agents Fungistatic Same mechanism of action as itraconazole Oral absorption good IV and oral dosage the same
What is itraconazole used for?
Azole group of antifungal agents Lower toxicity level Uses Systemic mycoses (alternative to ampho B) Mechanisms of action Inhibits the synthesis of ergosterol Inhibits fungal cytochrome P450-dependent enzymes
What is Ketoconazole (Formerly Nizoral)?
Azole group of antifungal agents Mechanism of action Inhibits ergosterol Uses: alternative to ampho B for systemic mycoses -Less toxic and only somewhat less effective -Slower effects -More useful in suppressing chronic infections than in treating severe, acute infections
The nurse is reviewing laboratory test results for a patient who is starting penicillin G. Which test result, if elevated, would suggest a contraindication to penicillin G? hematocrit and hemoglobin BUN and creatinine liver enzymes SGOT and ALT PT/INR
BUN and creatinine Rationale: Treatment with penicillin drugs requires normal kidney function. The BUN and creatinine level are indicators of kidney function. PT/INR is indicted for warfarin, not pencillin. Penicillin does not affect red cell production or cause bleeding so hematocrit and hemoglobin are not needed. SGOT and ALT are indicated for drugs that are hepatotoxic, which penicillin is not. See Lehne, p. 1062
What is indirect entry (hematogenous) of osteomyelitis?
Bacteria travels in bloodstream or spreads from nearby tissue to weak spots in bone and causes infection Common sites: Pelvis, tibia, & vertebrae (vascular rich areas) Children often have infection in growth plates (soft bone marrow)
What is chronic osteomyelitis?
Bone infection persisting for longer than 1 month Infection that has failed to respond to initial course of antibiotic therapy
How do we diagnose osteomyelitis?
Bone or soft tissue biopsy (most definitive) MRI/CT Scan X-ray (10 days+ for positive results) Doppler Angiogram CBC w/diff ESR Blood cx (gram neg = most common microorganism)
What generations of cephalosporins are highly resistant to beta lactamases?
Both 3rd & 4th generation highly resistant to beta lactamases reach clinically significant levels in CSF
What is Amphotericin B?
Broad-spectrum antifungal agent (also used against some protozoa) Highly toxic Infusion reaction and renal damage occur in all patients to varying degrees Must be given IV; no oral administration Uses Drug of choice for most systemic mycoses Before ampho B, systemic fungal infections were usually fatal
it is broad spectrum and has both bacteriostatic and bactericidal properties; side effects include GI (N&V, diarrhea, abdominal pain); you must stop the medication for any sign or report of tendon pain or swelling; should be avoided in the elderly; it is a fluoroquinolone
Ciprofloxacin
How do you treat systemic mycoses?
Classifications -Polyene antibiotics Amphotericin B Nystatin -Azoles Itraconazole (Sporanox) Fluconazole (Diflucan) Ketoconazole -Echinocandins -Flucytosine
What hematologic effects does amphotericin B cause?
Can cause bone marrow suppression Anemia: monitor hematocrit
What is a MRSA skin infection?
Can range from mild folliculitis to extensive furuncles Spread to other body areas and to other people Contact with skin or articles used by person with MRSA
What are CAUTIs?
Catheter-acquired UTIs Most common factor for UTI in health care centers Bacterial colonization starts along urethra and catheter by 48 hours. Bacterial biofilms develop on inner surface of catheter. 50% of patients with indwelling catheters become infected within 1 week.
5th generation, treats MRSA and penetrates BBB; bactericidal and broad spectrum; eliminated by the kidneys; belongs to the most widely used group of antibiotics- with 5 generations, cephalsporins
Ceftaroline
must use with caution combining this cephalosporin antibiotic with medications containing calcium (such as LR) as it could potentially cause fatal precipitates. To administer, flush line with normal saline before and after and calcium containing medications
Ceftriaxone
What are the preferred antimicrobials used for Bacterial Meningitis?
Ceftriaxone followed by Ampicillin (if ordered) followed by Vancomycin.
What are the preferred antimicrobials used to treat community acquired pneumonia?
Ceftriaxone followed by Azithromycin Moxifloxacin
What is an complicated UTI?
Coexists with presence of Obstruction Stones Catheters Diabetes/neurologic disease Pregnancy-induced changes Recurrent infection
What are the different types of pneumonia?
Community-Acquired Pneumonia (CAP) Medical Care-Association Pneumonia (MCAP) Aspiration Pneumonia Opportunistic Pneumonia
What are atypical clinical manifestations that often occur in older or debilitated patients?
Confusion or stupor Hypothermia Diaphoresis Anorexia Fatigue Myalgias Headache Abdominal pain
What are the clinical manifestations of pneumonia?
Cough May or may not be productive Sputum = Green, yellow, or rust-colored (bloody) Fever Shaking chills Dyspnea Tachypnea Pleuritic chest pain Viral pneumonia May initially be seen as influenza, with respiratory symptoms appearing and/or worsening 12 - 36 hours after onset
What is the etiology of pneumonia?
Etiology: Develops when respiratory defense mechanisms become incompetent or overwhelmed Decreased consciousness ->depresses cough and epiglottal reflexes Tracheal intubation interferes with cough reflex and mucociliary escalator mechanism Air pollution, viral URIs, normal changes of aging -> impaired mucociliary mechanism Chronic diseases suppress immune system
What are some examples of lower urinary tract infections?
Examples Cystitis: bladder Urethritis: urethra Prostatitis: prostate Usually no systemic manifestations
Amphotericin B causes nephrotoxicity. How do nurses minimize the damage?
Damage minimized by infusing 1 L of saline on days of treatment Extent of kidney damage related to total dose administered over the full course of treatment If total dose >4 g, residual impairment likely Avoid concurrent use of other nephrotoxic drugs Aminoglycosides, cyclosporines Nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided Monitor serum creatinine every 3-4 days Reduce dosage if >3.5 mg/dL
What are the clinical manifestations of osteomyelitis?
Fever Night sweats Chills Restlessness Nausea Malaise Constant bone pain unrelieved by rest and worsens with activity Inflammation and edema at site of infection
An hour after an amphotericin B infusion was started, the patient experiences a sudden episode of fever, chills, rigors, and nausea. Which drug, ordered as needed for this patient, should the nurse administer at this time? diphenhydramine (Benadryl) acetaminophen (Tylenol) dantrolene (Dantrium) hydrocortisone
Dantrolene Rationale: Fever, chills, rigors, and nausea are symptoms of an infusion reaction. This type of reaction occurs 1 to 3 hours after the infusion is started and can last for an hour. Intravenous dantrolene or meperidine is given for rigors. Pre-treatment with acetaminophen and diphenhydramine may reduce the occurrence of mild reactions. Glucocorticoids are used if other measures are ineffective, but reduce the patient's ability to fight the infection. See Lehne pg 1138.
you would want to give this drug if your patient becomes anxious, reports difficulty breathing, is noted to have wheezing, tachycardia, hypotension in reaction to a PCN you just started
Epinephrine:
What is a furuncle?
Deeper infection of follicle with Staphylococcus Small, tender, erythematous nodules that enlarge and become pus-filled and painful Lesions may be single or multiple; can recur Can be spread to other areas of body
What is osteomyelitis?
Definition Severe infection of the bone, bone marrow, & surrounding soft tissue Most common infecting microorganism = Staphylococcus aureus
What is opportunistic pneumonia?
Develops in immunocompromised patients -Severe protein-calorie malnutrition -HIV -Radiation, chemo, and immunosuppressive therapy Infection may result from microorganisms that do not normally cause disease in a healthy adult
What are Bactericidal drugs?
Directly lethal to bacteria at specific concentrations Ex: aminoglycosides (Gentamicin)
An older patient who recently was prescribed ciprofloxacin (Cipro) phones the prescriber's office complaining of pain above the heel while walking or stretching. The patient also takes a glucocorticoid. The nurse consults with the physician. Which instruction for the patient does the nurse expect to receive from the physician? Avoid the treadmill and apply ice to the area. Discontinue the medication and avoid exercising. Try isometric exercises prior to walking or stretching. Continue the medication and watch for redness or swelling.
Discontinue medication Rationale: Although rare, Cipro has caused tendon rupture especially of the Achille's tendon. The prescriber should be notified and the medication stopped. Until all evidence of tendonitis is eliminated, no further exercises should be attempted. See Lehne p. 1087.
broad spectrum and bacteriostatic; it is eliminated by the liver; should be avoided in the pediatric and pregnant patient population due to effects on bones and teeth discoloration; causes photosensitivity; when taken po, medication is affected by food so need to avoid calcium, milk, iron and antacids; it is a Tetracycline
Doxycycline
What are the diagnostic for pneumonia?
History and physical exam Rhonchi and crackles Consolidation = Bronchial breath sounds, egophony, and increased fremitus Pleural effusion = Dullness to percussion CXR May show typical pattern characteristic of infecting organism Following treatment, repeat CXR should be obtained no sooner than 6 - 8 weeks to assess for resolution Thoracentesis/Bronchoscopy with washings Used to obtain fluid samples for patients not responding to initial therapy Sputum specimen Cultured to find causative microorganism to determine proper antibiotic therapy Therapy should not be delayed due to inability to obtain sputum specimen (Increased morbidity and mortality rates) Blood cx Completed on seriously ill patients when sepsis is suspected ABGs Assess for hypoxia, hypercapnia, and acidosis CBC w/diff Leukocytosis occurs in majority of patients with bacterial pneumonia WBC > 15,000/uL with presence of bands
What are the diagnostics for UTIs?
History and physical examination Dipstick urinalysis Identify presence of nitrites, WBCs, and leukocyte esterase Urine for culture and sensitivity (if indicated) Clean-catch sample preferred Specimen by catheterization or suprapubic needle aspiration more accurate Determine bacterial susceptibility to antibiotics Urine specimen from catheter Cleanse port with disinfectant Aspirate urine from needleless port using sterile syringe
What are the treatment options for osteomyelitis?
IV antibiotic for at least 4-6 weeks May be followed by PO treatment if needed Patient's response to medication treatment monitored via bone scan and lab work (cbc, esr) Surgery Pain management Maintenance of mobility
When should IV antibiotic therapy be switched to PO medication for pneumonia?
IV antibiotic therapy should conclude when patient becomes hemodynamically stable & able to ingest oral medication Patients with PO meds may be discharged from hospital
What patients have an increased risk of UTI?
Immunosuppressed Diabetic Having undergone multiple antibiotic courses Have traveled to developing countries
What is direct entry (homogenous) of osteomyelitis?
Infection originates in the bone itself when an injury (penetrating wound, fx) exposes bone to bacteria Can occur in presence of foreign body (Ex. TKR/THR) Once in the blood, microorgranisms grow, increase pressure from nonexpanding nature of bone → ischemia & vascular compromise of periosteum Infection spreads through bone cortex and marrow cavity → cortical devascularization and necrosis Ischemia leads to osteonecrosis (bone death) Devitalized bone separates from surrounding living bone, forming sequestra Part of the periosteum that continues to have blood supply forms new bone called involucrum (Fig. 63-1) Difficult for abx or wbcs to reach sequestrum May become reservoir for microorganisms that spread to other sites (lungs, brain, etc.) If not resolved on its own or surgically debrided, a sinus tract may develop → chronic purulent cutaneous drainage.
What are health care-associated infections (HAI)?
Infections acquired through exposure to a pathogen in a health care setting Hospitals Diagnostic testing facilities/equipment Outpatient surgery centers Medical/dental offices Long-term care facilities Many patients are high-risk and can develop an infection that would not affect the normal population Hand-washing and use of gloves are still first line defense to prevent spread through direct contact.
What are emerging infection?
Infections that have, in recent decades, increased in incidence or threaten to increase Come from unknown sources, animal contact (zoonosis), biologic warfare
What are prions?
Infectious particles with abnormal proteins If disease-causing, affect nervous system Creutzfeld-Jakob disease Bovine spongiform encephalopathy (Mad Cow disease)
What are viruses?
Infectious particles with no cellular structure Consist of small amount of genetic material and a protein envelope Reproduce (spread) by releasing genetic material into cells of another living organism Examples: Hepatitis Herpesviruses Influenza Rhinovirus
do not give if the patient is allergic to eggs; should wait for symptoms to subside if patient has a febrile illness; protection from this medication begins 1-2 weeks after it is received and lasts 4-6 months depending on the person's age. It is best to give around October.
Influenza Immunization
What is aspiration pneumonia?
May be CAP or MCAP Abnormal entry of material from mouth or stomach into the trachea and lungs Increased risk Altered LOC Dysphagia NG tube Aspirated material causes an inflammatory response Treatment is based on origination of infection and probable causative agent (CAP vs. MCAP) Aspiration of acidic gastric contents causes chemical (noninfectious) pneumonitis and may not require antibiotic therapy Secondary bacterial infection can occur 48 - 72 hours later
What are second generation cephalosporins commonly used for?
May be used for respiratory, abdominal, or pelvic infections
What can result from a fever above 104?
May damage cells Delirium and seizures may occur Should be treated
What are the side effects of Ciprofloxacin (Cipro)?
Mild GI - nausea/vomiting, diarrhea, abdominal pain CNS - dizziness, headache, restlessness, confusion, rarely seizures Candida infections - pharynx and vagina *Low, but serious risk of Achilles tendon rupture* Risk of phototoxicity Elderly patients Significant risk for confusion, somnolence, psychosis, visual disturbances
What are some ways to manage a fever in patients?
Monitor temperature and VS Adjust environment to meet pt needs Linen changes may be necessary Administer antipyretics as ordered Antipyretics reduce the thermostatic set point Sponge baths and cooling blankets are adjunctive interventions Not generally effective at lowering body temperature unless used with antipyretic
What are the complications of pneumonia?
More common in elderly patients and patients with chronic diseases Pleurisy: Inflammation of pleura Pleural effusion: Fluid in pleural cavity Usually is self-resolving, but occasionally requires thoracentesis Atelectasis: Collapsed, airless alveoli Encourage CTDB and IS Sepsis: Bacterial infection in bloodstream Severe sepsis can lead to shock, multisystem organ dysfunction syndrome (MODS), and death Acute respiratory failure: Pneumonia damages lungs' ability to exchange O2 and CO2 Leading causes of death in patients with pneumonia Less common complications Lung abscess, empyema, pericarditis, meningitis, and pneumothorax
What are dermatophyte infections?
Most are relatively harmless to healthy adult Superficial infection Starts when organism comes into direct contact with impaired skin in a susceptible host Example: Tinea unguium also known as onychomycosis Scaliness underneath a nail with nails becoming brittle, thickened, broken or crumbling a
What is Herpes simplex (HSV)?
Most common viral skin infection in adults *Type I - classic cold sore* Type 2 - genital herpes Recurrent lifelong infections Dormant in nerve ganglia after 1st infection Recurrence triggered by stressors: dry lips, sunburn, menses, fatigue, fever Can be spread by contact with active lesion or virus-containing fluid (saliva)
What are aminoglycosides?
Most common: gentamicin, tobramycin, amikacin Bactericidal Narrow -spectrum Used to treat serious infections Adverse reactions Ototoxicity Nephrotoxicity Monitor trough and peak serum levels Levels may vary among patients at same dose Trough levels must be low enough to minimize toxicity, but peak levels need to be high enough to kill bacteria Timing important - peak levels: 30 minutes after administration, trough levels: prior to next dose
First generation cephalosporin drugs are mostly used for?
Most widely used for pre-op prophylaxis Rarely used for active infections
How do we manage pain in patients with osteomyelitis?
Muscle spasms -NSAIDs, opioids, and muscle relaxants -Non-drug = Guided imagery, relaxation breathing, frequent repositioning, etc. Immobilize limb to decrease px Limited weight-bearing
What are the adverse effects of Fluconazole (Diflucan)?
Nausea Headache Vomiting Abdominal pain Diarrhea
What is Ceftaroline (Teflaro)?
New cephalosporin *Only cephalosporin effective against MRSA* May be classified as 3rd generation because of antimicrobial spectrum, but sometimes classified as 5th generation
What is systemic mycoses?
Systemic mycoses are fungal infections affecting internal organs. In the right circumstances the fungi enter the body via the lungs, through the gut, paranasal sinuses or skin. Treatment can be difficult Infections often resist treatment Treatment may require prolonged therapy with drugs that frequently prove toxic
What is an uncomplicated UTI?
Occurs in otherwise normal urinary tract Usually involves only the bladder
What is cellulitis?
Often follows break in skin Localized inflammation of subcutaneous tissues that can rapidly enlarge if not treated Deep inflammation from enzymes produced by bacteria Staphylococcus or Streptococcus Hot, tender, erythematous, and edematous area Systemic symptoms including chills, fever, malaise, and lymphadenopathy
Who is a greater risk for infections?
Older patients and the immunosuppressed Risk for HAI is 2x - 3x greater Impaired immune function Co-morbidities such as diabetes Atypical presentation Cognitive and behavioral changes before usual signs of fever, pain, or changes in lab values Recall that older adults typically have lower core body temperature Acute inability to perform daily activities
What are bacteria?
One celled organisms Commonly found throughout nature and within our bodies Serve protective function in maintaining balance of microorganisms If out of balance, can cause infection Example: Escherichia coli Cause disease in two ways Grow inside cells Secrete toxins that damage cells from outside Classified by shape
What is the etiology of UTIs?
Organisms introduced via ascending route from the perineum to the urethra Contributing factors Anything causing urinary stasis or incomplete emptying Men: enlarged prostate Women: cystocele or vaginal prolapse; atrophic changes due to decreased estrogen post-menopause Sexual intercourse Urologic instrumentation catheters scopes Hospital-acquired UTI accounts for 31% of all health-care associated infections. Escherichia coli most common pathogen Fungal and parasitic infections are less common cause
given po; it is important to know the onset of symptoms to determine benefit of this drug; it reduces symptom duration and severity of influenza.
Oseltamivir
What is community-acquired pneumonia?
Patient has not been hospitalized or resided in a long-term care facility within 14 days of the onset of symptoms Depending on severity of infection, patient may or may not be hospitalized Evaluation based on Physician experience CURB-65 scale (Table 27 - 3) Pneumonia Patient Outcomes Research Team (PORT) Pneumonia Severity Index Empiric antibiotic therapy should be initiated ASAP
How can nurses prevent pneumonia?
Patient with altered LOC should be placed in side-lying or upright position Turn and reposition patient Q2H Promote lung expansion and decrease secretion pooling Assist with ambulation and sitting in chair Strict adherence to VAP bundle (Critical care) Orogastric or nasogastric tubes - keep HOB 30 - 45 degrees and monitor residuals Avoid inappropriate use of antibiotic therapy to prevent development of drug-resistant organisms Interdisciplinary teams include Respiratory Therapy Physical Therapy Occupational Therapy Speech Therapy Dietary
Most are eliminated by the kidneys so dose may need to be lowered based on Creatinine clearance, BUN/Cr; Diarrhea is the most common side effect; adverse reaction could be mild rash to anaphylaxis; if anaphylaxis you must also consider cross sensitivities to cephalosporins.
Penicillin
What are the surgical treatment options for osteomyelitis?
Peripheral Angioplasty -Restore blood flow to affected area -Possible stent placement Incision and Debridement (I&D) -Surgical removal of diseased and necrotic bone/tissue with drainage of the infected area -Removal of any foreign objects Amputation of the affected limb -Reserved for life-threatening infections and QOL improvement for chronic osteomyelitis patients Muscle flap or skin graft for wound coverage
What are the preferred antimicrobials used for intra-abdominal infections?
Piperacillin/Tazobactam Ceftriaxone or Cefepime followed by Metronidazole
What are the preferred antimicrobials used to treat hospital-acquired pneumonia?
Piperacillin/Tazobactam or Cefepime followed by vancomycin
What are the side effects of Ceftriaxone (Rocephin) + calcium?
Potentially fatal precipitates Give oral calcium and parenteral ceftriaxone Do not give IV ceftriaxone with calcium-containing IVF Ringer's solutions
What are the adverse reactions from cephalosporins?
Rare Allergic reactions Most common: maculopapular rash within several days of starting treatment Severe anaphylactic reaction rare: epinephrine & respiratory support Rarely may see cross-reactivity with penicillin
What are the risk factors for osteomyelitis?
Recent injury or orthopedic surgery -Fracture -Joint *replacement/Implanted orthopedic hardware* Circulation Disorders -Uncontrolled Diabetes -PAD -Sickle Cell Disease
When is the Pneumococcal vaccine recommended?
Recommendations for Initial Vaccination 65+ yoa 2-64 yoa with long-term health problems or conditions that compromise immune system 19-64 yoa who smoke or have asthma Residents of long-term care facilities Revaccination Recommendations 65+yoa who received initial vaccine more than 5 years ago and were less than 65 yoa at the time of vaccination 2-64 yoa with long-term health problems or conditions that compromise immune system If 5 years have elapsed since receipt of first vaccine
What are some examples and side effects of upper urinary tract infections?
Renal parenchyma, pelvis, and ureters Typically causes fever, chills, flank pain Example Pyelonephritis: inflammation of renal parenchyma and collecting system
What can result from a fever above 105.8?
Temperature control center impaired Brain damage possible
What are some resistant microbial organisms?
Resistant microbial organisms -Vancomycin resistant enterococci (VRE) - hardier than MRSA, requires antiseptic soap (chlorhexadine) -Enterococcus faecalis - also streptomycin & gentamicin -Enterococcus faecium - same as above -Staphylococcus aureus (MRSA) - viable for days on environmental surfaces & clothing -Staphylococcus epidermidis - methicillin -Streptococcus pneumoniae - penicillin G resistant -Klebsiella pneumoniae - 3rd generation cephalosporins
What is the patho of UTIs?
Result of interaction between a host and pathogens Normal host resistance is overcome Immunocompromised host at higher risk Infectious cystitis or UTI Most commonly caused by pathogens from bowel Organisms adhere to perineum, are introduced into the urethra and migrate to the bladder Women at greater risk - shorter urethra than men Can lead to life-threatening pyelonephritis and urosepsis
What is vancomycin used for?
Severe infections only -Methicillin-resistant Staphylococcus aureus or Staphylococcus epidermidis -Pseudomembranous colitis associated with antibiotic use Oral dose used for Clostridium difficile if metronidazole (Flagyl) ineffective
What are the side effects of Itraconazole (Sporanox)?
Side effects (well tolerated in usual doses) -Cardiosuppression Transient decrease in ventricular ejection fraction -Liver damage Watch for signs of liver dysfunction -Can inhibit drug-metabolizing enzymes -GI effects Nausea, vomiting, diarrhea
What are fungi?
Similar to plants but no chlorophyll Infections usually localized, but can spread if host is immunocompromised Mycosis - any disease caused by a fungus Examples: Tinea pedis (athlete's foot) Candida albicans (thrush) Hard to treat
What are protozoa?
Single-cell microorganisms that live in soil and water Function as parasites in the human body Examples Amebic dysentery Malaria
What is the nutritional therapy for patients with pneumonia?
Small, frequent meals with foods high in calories and nutrients Eating becomes difficult for dyspneic patients (SOB and pleuritic pain) Body has increased metabolic needs
What is a suprainfection?
Special example of drug resistance Antibiotics eliminate the inhibitory influence of normal flora and allow a new infectious agent to develop More common with broad-spectrum antibiotics Common example: thrush (Candida albicans), antibiotic-associated diarrhea (Clostridium difficile)
What are infection precautions?
Standard Precautions Care of ALL patients in health care setting Transmission-based Precautions For known or suspected infections of highly transmissible pathogens Purpose - to interrupt transmission and prevent infection of others Airborne - organism can cause infection over long distances through the air (TB) Droplet - spread through air at close contact (influenza) Contact - spread by direct contact (multidrug resistant organisms)
What is folliculitis?
Superficial infection involving only upper portion of hair follicle Isolated pustule with occasional papules Tender to touch Generally caused by Staphylococcus Can be spread to other areas of body
What is the CURB-65 Scale?
Supplement tool to determine severity of pneumonia and need for hospitalization Identifying Level of Risk Patients receive 1 point for each of the following indicators: C: Confusion (compared to baseline) U: BUN > 20mg/dL R: Respiratory rate 30+ breaths/min B: SBP < 90mmHg or DBP <60mmHg 65: 65+yoa Scoring & Decision Making 0 points: Treat at home 1-2 points: Consider hospital admission 3+ points: Hospital admission 4-5 points: Consider admission to ICU
When are antibiotics used prophylactically?
Surgery - 1st generation cephalosporin Cardiac, Peripheral vascular, Orthopedic, GI tract, Gynecologic surgery, and Dirty surgeries - wounds are considered infected, drugs given to treat assumed infection Prevention of bacterial endocarditis Post-joint replacements prior to any dental or medical procedure that could introduce bacteria into bloodstream Neutropenia May reduce incidence of bacterial infection, but increase risk of fungal growth Recurrent urinary tract infections
What is the preferred antimicrobial used to treat UTIs?
ceftriaxone
What are narrow spectrum antibiotics?
effective against a few microorganisms Aminoglycosides - gentamicin, amikacin, tobramycin vancomycin
What are broad spectrum antibiotics?
effective against wide variety Penicillins: penicillin G, ampicillin Cephalosporines - cephalexin, cefoxitin, cefotaxime, cefepime Carbapenems - imipenem (Primaxin) Tetracyclines - doxycycline (Vibramycin) Macrolides - erythromycin
What are the signs of red man syndrome?
flushing, pruritus, urticaria, tachycardia, & hypotension is an infusion-related reaction peculiar to vancomycin [3]. It typically consists of pruritus, an erythematous rash that involves the face, neck, and upper torso
What are the most common clinical manifestations of UTIs?
frequency, urgency, dysuria suprapubic discomfort Other manifestations: changes to urine cloudy, foul-smelling, or blood-tinged Upper urinary tract manifestations flank pain chills and fever
The nurse is caring for a patient receiving gentamicin intravenously (IV). To decrease the risk of ototoxicity, the nurse will ask the patient to report which of the following symptoms? dizziness high-pitched ringing ear pain tone deafness
high-pitched ringing Rationale: Aminoglycosides can be toxic to the inner ear which is supplied by the vestibulo-coclear nerve. The first sign of impending cochlear damage (hearing) is high-pitched tinnitus (ringing in the ears). As injury to cochlear hair cells proceeds, hearing in the high-frequency range begins to decline. Vestibular damage which causes balance problems is initially experienced as a headache which may last 1 to 2 days. Nausea, unsteadiness, dizziness, and vertigo then begin to appear. Tone deafness is difficulty identifying musical pitches and/or notes. Lehne p. 1055
What are the beneficial aspects of a fever?
increased killing of microorganisms, increased phagocytosis, and increased proliferation of T lymphocytes.
What is prostatitis?
inflammation of the prostate gland Can mimic cystitis Acute cystitis uncommon in men Organisms reach prostate gland by Ascending from urethra Descending from bladder Via bloodstream or lymphatic channels
What are bacteriostatic drugs?
majority Slow down bacterial growth, but not lethal Healthy immune system works with phagocytes to eliminate bacteria Ex: tetracyclines
What is the drug therapy for fungal dermatological infections?
topical Dermatophytes: difficult to eradicate even with prolonged treatment Treatment for onychomycosis is optional Candidiasis: Oral: Nystatin - requires 1 - 2 weeks after symptoms gone Vaginal: clotrimazole - dosing depends on formulation: 3 - 7 days