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Ch. 38 & 39

Community associated infections Infection acquired by a person who has not been hospitalized or had medical procedure (dialysis, surgery, catheterization) within the past year
Healthcare associated infections Contracted in a hospital or institutional setting. Were not present or incubating in the patient on admission. More difficult to treat due to causative microorganisms often being drug resistant and virulent
Healthcare associated infections (continued) 1 of top 10 leading causes of death in US. MRSA (most common)
Disinfectant Kills organisms. Used only on nonliving objects
Antiseptic Inhibits microorganism growth, but doesn't kill. Apply to living tissue
Antibiotics Medications used to treat bacterial infections. Try to identify causative agent before administration of medication.
Antibiotic therapy Empiric: treatment of an infection before specific culture information has been reported. Definitive: tailored to treat organism identified with cultures. Prophylactic: to prevent infection
Antibiotic classes Sulfonamides. Penicillins. Cephalosporins. Macrolides. Quinolines. Aminoglycosides. Tetracyclines.
Antibiotic therapy: Mechanisms of action Interferes with cell wall synthesis. Interferes with protein synthesis. Interferes with DNA replication. Disrupts critical metabolic reactions inside bacterial cell wall.
Sulfonamides Sulfadiazine. Sulfamethoxazole. Sulfisoxazole. Bactrim (Sulfamethoxazole + trimethoprim)
Sulfonamides: Mechanisms of action Bacteriostatic. Inhibit sythesis of folic acid required for synthesis of purines and nucleic acid. Don't affect human cells or certain bacteria. Only affect organisms that synthesize their own folic acid.
Sulfonamides: Indications I Effective against both Gram - and Gram + bacteria.
Sulfonamides: Indications II Treatment of UTIs caused by susceptible strains of: Enterbacter spp,E. coli, Klebsiella spp, Proteus mirabilis, Proteus vulgaris, S. aureus, Pneumocystis jirovecii pneumonia, Co-trimoxazole, Upper respiratory infections
Penicillins Natural penicillins; Penicillinase-resistant drugs; Aminopenicillins; Extended-spectrum drugs
Penicillins: Negative Bacteria produce enzymes (beta-lactamases) capable of destroying penicillins. (Chemicals that inhibit these enzymes: Calvulanic acid, tazobactam, sulbactam)
Penicillins: Mechanism of Action Bactericidal. Inhibit cell wall synthesis. Inside cell they bind to penicillin-binding protein. Normal cell wall synthesis is disrupted. Bacteria cells then die from cell lysis. *Do not kill other cells in the body.
Penicillins: Indications Gram + bacteria, Streptococcus, Enterococcus, Staphylococcus
Penicillins: Adverse Effects Urticaria, pruritus, angioedema, n/v, runs, abdominal pain, hives (rare). If patient is allergic to penicillin, may be allergic to cephalosporin as well.
Penicillins: Interactions NSAIDs (ibuprofen) – compete with the drug for protein binding, more free penicillin may result (toxic risk). Oral contraceptives–Decreases efficacy of the contraceptive. Warfarin-Blood becomes thinner than expected
Cephalosporins Semisynthetic derivatives. Structurally and pharmacologically related to penicillins. Bactericidal. Broad spectrum. Divided into groups according to antimicrobial activity
Cephalosporins: First Generation Used for surgical prophylaxis. Good Gram + coverage. Poor Gram - coverage. Parenteral and PO forms (Examples: cefadroxil, cephradine, cefazolin, cephalexin); Cefazolin: IV or IM; Cephalexin: PO.
Cephalosporins: Second Generation I Good Gram + coverage. Better Gram - coverage than first generation (Examples: cefaclor, cefprozil, cefoxitin)
Cephalosporins: Second Generation II Cefoxitin (Mefoxin): IV or IM, Used for abdominal or colorectal surgeries. Also kills anaerobes; Cefuroxime, Surgical prophylaxis. Doesn't kill anaerobes
Cephalosporins: Third Generation I Most potent group against Gram - bacteria. Less active against Gram + bacteria (Examples: ceftibuten cefotaxime, ceftazidime, cefdinir, ceftizoxime, ceftriaxone, ceftazidime)
Cephalosporins: Third Generation II Ceftriaxone (Rocephin): IV and IM, long half-life, once-a-day dosing. Elimination is primarily hepatic. Easily passes meninges and diffused into CSF to treat CNS infections
Cephalosporins: Third Generation III Ceftazidime (Ceptaz): IV and IM forms. Excellent Gram - coverage. Used for hard to treat organisms (Pseudomonas spp.) Eliminated by renal route, not biliary. Resistance is limiting usefulness
Cephalosporins: Fourth Generation I Broader spectrum third generation, especially against Gram + bacteria. UTI. Cefepime (Maxipime)
Cephalosporins: Fifth Generation Not available yet. Broader spectrum. Effective against a wide variety of organisms (MRSA, Pseudomonas spp.)
Cephalosporins: Adverse affects Similar to penicillins. Mild runs, abdominal cramps, rash, pruritus, redness, edema Potential cross-sensitivity with penicillins if allergies exist
Carbapenems I Very broad-spectrum. Reserved for complicated body cavity and connective tissue infections. May cause drug-induced seizure activity. All given parenterally
Carbapenems II Imipenem/Cilastatin (Primaxin). Used for treatment of bone, joint, skin, and soft-tissue infections
Monobactams Aztreonam (Azactam). Synthetic beta-lactam antibiotic: Primarily active against aerobic Gram - bacteria (E. coli, Klebsiella spp., Pseudomonas spp.); Bactericidal. Parenteral use only. Used for moderately severe systemic infections and UTIs.
Macrolides Erythromycin (E-mycin, E.E.S), azithromycin (Zithromax), clarithromycin (Biaxin), dirithromycin
Macrolides: Mechanism of Action Bacteriostatic. Inhibit protein synthesis within bacterial cells. In high enough concentrations, may also be bactericidal
Macrolides: Indications Strep infections, Streptococcus pyogenes, Mild to moderate URI and LRI, Haemophilus influenzae, Spirochetal infections, Syphilis and Lyme disease, Gonorrhea, Chlamydia, Mycoplasma
Ketolide I Active against Gram +, including multi–drug-resistant strains of S. pneumoniae. Associated with severe liver disease.
Ketolide II Telithromycin (Ketek), Only drug in this class. Community-acquired pneumonia, acute bacterial sinusitis, acterial exacerbations of chronic bronchitis
Ketolide: Adverse reactions: Headache, dizziness, GI discomfort, altered potassium levels, prolonged QT intervals
Tetracyclines I Bacteriostatic. Inhibit protein synthesis. Natural and semisynthetic. Obtained from cultures of Streptomyces. Dairy products, antacids, and iron salts reduce oral absorption
Tetracyclines II Demeclocycline (Declomycin), oxytetracycline, tetracycline, doxycycline (Doryx, Vibramycin), minocycline, tigecycline (Tygacil)
Tetracyclines: Indications Broad spectrum. Gram - and Gram + organisms (protozoa, Mycoplasma, Rickettsia, Chlamydia, syphilis, Lyme disease, acne). Demeclocycline is also used to treat SIADH by inhibiting the action of ADH
Tetracyclines: Adverse Effects I Strong affinity for calcium. Discoloration of permanent teeth and tooth enamel in fetuses and children, or nursing infants if taken by the mother. May retard fetal skeletal development.
Tetracyclines: Adverse Effects II Alteration in intestinal flora may result in: Superinfection, Diarrhea, Pseudomembranous colitis, Vaginal candidiasis Gastric upset, Enterocolitis, Maculopapular rash
Nursing Implications I Assess drug allergies; renal, liver, and cardiac function; obtain thorough patient health history; Assess for conditions that may be contraindications to antibiotic use; Assess for potential drug interactions
Nursing Implications II obtain cultures from appropriate sites BEFORE beginning antibiotic therapy; Instruct patients to take antibiotics exactly as prescribed
Nursing Implications III Assess for signs and symptoms of superinfection; check the name of the medication carefully because there are many drugs that sound alike or have similar spellings
Nursing Implications: Sulfonamides Take with 2000 to 3000 mL of fluid/24 hr; Assess RBCs prior to beginning therapy; Take oral doses with food; Take oral doses with water, not juices; Monitor patients at least 30 minutes after administration
Nursing Implications: Cephalosporins Assess for penicillin allergy; may have cross allergy. Give orally administered forms with food, even though this will delay absorption; Some of these drugs may cause a disulfiram (Antabuse)-like reaction when taken with alcohol
Nursing Implications: Macrolides Highly protein-bound and will cause severe interactions with other protein-bound drugs. Take erythromycin on empty stomach, but because of the high incidence of GI upset, many drugs are taken after a meal or snack
Nursing Implications: Tetracyclines Avoid milk products, iron preparations, antacids, and other dairy products because of the chelation and drug-binding that occurs. Take all medications with 6 to 8 ounces of fluid; avoid sunlight and tanning beds
Antibiotic Therapy: Concepts I Multidrug resistance; Therapeutic drug monitoring; Minimum inhibitory concentration (MIC); Time-dependent killing;
Antibiotic Therapy: Concepts II Concentration-dependent killing; Once-daily dosing vs. multi-daily dosing; Peak and trough blood levels; Synergistic effects Post-antibiotic effect (PAE)
Antibiotic Therapy: Toxicities I Ototoxicity: Temporary or permanent hearing loss, balance problems. Nephrotoxicity: Varying degrees of reduced renal function. Rising serum creatinine may indicate reduced creatinine clearance;
Antibiotic Therapy: Toxicities II Monitor trough levels every 5 to 7 days; Monitor serum creatinine levels every 3 days
Aminoglycosides I Gentamicin (Garamycin); kanamycin; neomycin (Neo-Fradin); streptomycin; tobramycin (Nebcin); amikacin (Amikin)
Aminoglycosides I Natural and semisynthetic. Produced from Streptomyces. Poor oral absorption; no PO forms. Very potent antibiotics with serious toxicities. Bactericidal; prevents protein synthesis. Kill mostly gram-negative; some gram-positive also
Aminoglycosides: Indications Gram -. Poorly absorbed through the GI tract. Given parenterally. (Exception: Neomycin. Given orally to decontaminate the GI tract before surgical procedures)
Aminoglycosides: Adverse Effects I Cause serious toxicities. Nephrotoxicity: renal damage. Ototoxicity: auditory impairment and vestibular impairment. Must monitor drug levels to prevent toxicities
Aminoglycosides: Adverse Effects II Ototoxicity and nephrotoxicity are the most significant. Headache, Paresthesia, Fever, Superinfections, Vertigo, Skin rash, Dizziness
Fluoroquinolones I ciprofloxacin (Cipro), norfloxacin (Noroxin), levofloxacin (Levaquin), gatifloxacin (Tequin), moxifloxacin (Avelox), gemifloxacin (Factive)
Fluoroquinolones II Excellent oral absorption Absorption reduced by antacids Effective against Gram - organisms and some Gram + organisms
Fluoroquinolones: Mechanism of Action Bactericidal. Alter bacterial DNA, causing death. Do not affect human DNA
Fluoroquinolones: Indications Gram - bacteria such as pseudomonas. Respiratory infections. Bone and joint infections. GI infections. Skin infections. STDs. Anthrax
Fluoroquinolones: Adverse Effects I Headache, dizziness, fatigue, depression, restlessness, insomnia. n/v, runs, constipation, thrush, increased liver function. Prolonged QT interval
Fluoroquinolones: Adverse Effects II Rash, pruritus, urticaria, flushing, photosensitivity. Fever, chills, blurred vision, tinnitus. Black box warning: increased risk of tendonitis and tendon rupture
Other Antibiotics I clindamycin (Cleocin); linezolid (Zyvox); metronidazole (Flagyl); nitrofurantoin (Macrodantin); quinupristin and Dalfopristin (Synercid); daptomycin (Cubicin); vancomycin (Vancocin); colistimethate (Coly-mycin)
Other Antibiotics: Clindamycin Used for chronic bone infections, GU infections, intraabdominal infections. May cause pseudomembranous colitis.
Other Antibiotics: Linezolid New class: oxazolidinones. Used to treat vancomycin-resistant Enterococcus faecium (VREF), hospital-acquired skin and skin structure infections (MRSA). May cause hypotension, serotonin syndrome if taken with SSRIs
Other Antibiotics: Metronidazole Used for anaerobic organisms. Intraabdominal and gynecologic infections. Protozoal infections.
Other Antibiotics: Nitrofurantoin Primarily used for UTIs. Use carefully if renal function is impaired. Drug concentrates in the urine. May cause fatal hepatotoxicity Usually well-tolerated if patient is kept well-hydrated
Other Antibiotics: Quinupristin & Dalfopristin Used for bacteremia and infections caused by vancomycin-resistant Enterococcus (VRE) and other skin infections. May cause arthralgias, myalgias
Other Antibiotics: Daptomycin New class: lipopeptide. Used to treat complicated skin and soft-tissue infections
Other Antibiotics: Vancomycin I Bactericidal. Gram +. Destroys cell wall. Treats MRSA. May cause ototoxicity and nephrotoxicity. Should be infused over 60 minutes. Rapid infusions may cause hypotension
Other Antibiotics: Vancomycin II Monitor IV site closely. Red man syndrome may occur. Flushing/itching of head, neck, face, upper trunk. Ensure adequate hydration, 2 L fluids per 24 hr if not contraindicated to prevent nephrotoxicity. Monitor trough levels carefully.
Therapeutic Decrease in specific signs and symptoms of infection are noted
Subtherapeutic Signs and symptoms do not improve
Bactericidal Kill bacteria
Bacteriostatic Inhibit growth of susceptible bacteria (eventually leads to bacterial death)
Sulfonamides: Adverse affects I Blood Hemolytic and aplastic anemia, agranulocytosis, thrombocytopenia, photosensitivity, exfoliative dermatitis, Stevens-Johnson syndrome, epidermal necrolysis,
Sulfonamides: Adverse affects II n/v, runs, pancreatitis, crystalluria, toxic nephrosis, headache, peripheral neuritis, urticaria
Beta-Lactam Antibiotics Gram -. (Penicillins, cephalosporins, carbapenems, monobactams, beta-latam ring)
Sulfonamides Sulfadiazine
Sulfonamides Sulfamethoxazole
Sulfonamides Sulfisoxazole
Sulfonamides Bactrim (Sulfamethoxazole + trimethoprim)
Cephalosporins cefadroxil
Cephalosporins cephradine
Cephalosporins cefazolin
Cephalosporins cephalexin
Cephalosporins Cefazolin
Cephalosporins Cephalexin
Cephalosporins Cefoxitin (Mefoxin
Cephalosporins Cefuroxime
Cephalosporins Ceftriaxone (Rocephin)
Cephalosporins Ceftazidime (Ceptaz)
Cephalosporins Cefepime (Maxipime)
Carbapenems Imipenem/Cilastatin (Primaxin)
Monobactams Aztreonam (Azactam)
Macrolides Erythromycin (E-mycin, E.E.S)
Macrolides azithromycin (Zithromax)
Macrolides clarithromycin (Biaxin)
Macrolides dirithromycin
Ketolide Telithromycin (Ketek)
Tetracyclines Demeclocycline (Declomycin)
Tetracyclines oxytetracycline
Tetracyclines tetracycline
Tetracyclines doxycycline (Doryx, Vibramycin)
Tetracyclines minocycline
Tetracyclines tigecycline (Tygacil)
Aminoglycosides Gentamicin (Garamycin)
Aminoglycosides kanamycin
Aminoglycosides neomycin (Neo-Fradin)
Aminoglycosides streptomycin
Aminoglycosides tobramycin (Nebcin)
Aminoglycosides amikacin (Amikin)
Fluoroquinolones ciprofloxacin (Cipro)
Fluoroquinolones norfloxacin (Noroxin)
Fluoroquinolones levofloxacin (Levaquin)
Fluoroquinolones gatifloxacin (Tequin)
Fluoroquinolones moxifloxacin (Avelox)
Fluoroquinolones gemifloxacin (Factive)
Created by: maggardba