Ch. 38 & 39
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| Community associated infections | Infection acquired by a person who has not been hospitalized or had medical procedure (dialysis, surgery, catheterization) within the past year
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| 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
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| Healthcare associated infections (continued) | 1 of top 10 leading causes of death in US. MRSA (most common)
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| Disinfectant | Kills organisms. Used only on nonliving objects
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| Antiseptic | Inhibits microorganism growth, but doesn't kill. Apply to living tissue
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| Antibiotics | Medications used to treat bacterial infections. Try to identify causative agent before administration of medication.
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| 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
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| Antibiotic classes | Sulfonamides. Penicillins. Cephalosporins. Macrolides. Quinolines. Aminoglycosides. Tetracyclines.
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| 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.
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| Sulfonamides | Sulfadiazine. Sulfamethoxazole. Sulfisoxazole. Bactrim (Sulfamethoxazole + trimethoprim)
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| 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.
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| Sulfonamides: Indications I | Effective against both Gram - and Gram + bacteria.
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| 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
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| Penicillins | Natural penicillins; Penicillinase-resistant drugs; Aminopenicillins; Extended-spectrum drugs
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| Penicillins: Negative | Bacteria produce enzymes (beta-lactamases) capable of destroying penicillins. (Chemicals that inhibit these enzymes: Calvulanic acid, tazobactam, sulbactam)
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| 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.
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| Penicillins: Indications | Gram + bacteria, Streptococcus, Enterococcus, Staphylococcus
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| 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.
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| 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
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| Cephalosporins | Semisynthetic derivatives. Structurally and pharmacologically related to penicillins. Bactericidal. Broad spectrum. Divided into groups according to antimicrobial activity
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| 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.
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| Cephalosporins: Second Generation I | Good Gram + coverage. Better Gram - coverage than first generation (Examples: cefaclor, cefprozil, cefoxitin)
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| 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
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| Cephalosporins: Third Generation I | Most potent group against Gram - bacteria. Less active against Gram + bacteria (Examples: ceftibuten
cefotaxime, ceftazidime, cefdinir, ceftizoxime, ceftriaxone, ceftazidime)
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| 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
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| 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
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| Cephalosporins: Fourth Generation I | Broader spectrum third generation, especially against Gram + bacteria. UTI. Cefepime (Maxipime)
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| Cephalosporins: Fifth Generation | Not available yet. Broader spectrum. Effective against a wide variety of organisms (MRSA, Pseudomonas spp.)
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| Cephalosporins: Adverse affects | Similar to penicillins. Mild runs, abdominal cramps, rash, pruritus, redness, edema
Potential cross-sensitivity with penicillins if allergies exist
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| Carbapenems I | Very broad-spectrum. Reserved for complicated body cavity and connective tissue infections.
May cause drug-induced seizure activity. All given parenterally
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| Carbapenems II | Imipenem/Cilastatin (Primaxin). Used for treatment of bone, joint, skin, and soft-tissue infections
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| 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.
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| Macrolides | Erythromycin (E-mycin, E.E.S), azithromycin (Zithromax), clarithromycin (Biaxin), dirithromycin
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| Macrolides: Mechanism of Action | Bacteriostatic. Inhibit protein synthesis within bacterial cells. In high enough concentrations, may also be bactericidal
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| Macrolides: Indications | Strep infections, Streptococcus pyogenes, Mild to moderate URI and LRI, Haemophilus influenzae, Spirochetal infections, Syphilis and Lyme disease, Gonorrhea, Chlamydia, Mycoplasma
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| Ketolide I | Active against Gram +, including multi–drug-resistant strains of S. pneumoniae. Associated with severe liver disease.
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| Ketolide II | Telithromycin (Ketek), Only drug in this class. Community-acquired pneumonia, acute bacterial sinusitis, acterial exacerbations of chronic bronchitis
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| Ketolide: Adverse reactions: | Headache, dizziness, GI discomfort, altered potassium levels, prolonged QT intervals
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| Tetracyclines I | Bacteriostatic. Inhibit protein synthesis. Natural and semisynthetic. Obtained from cultures of Streptomyces. Dairy products, antacids, and iron salts reduce oral absorption
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| Tetracyclines II | Demeclocycline (Declomycin), oxytetracycline, tetracycline, doxycycline (Doryx, Vibramycin), minocycline, tigecycline (Tygacil)
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| 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
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| 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.
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| Tetracyclines: Adverse Effects II | Alteration in intestinal flora may result in: Superinfection, Diarrhea, Pseudomembranous colitis, Vaginal candidiasis
Gastric upset, Enterocolitis, Maculopapular rash
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| 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
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| Nursing Implications II | obtain cultures from appropriate sites BEFORE beginning antibiotic therapy; Instruct patients to take antibiotics exactly as prescribed
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| 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
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| 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
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| 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
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| 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
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| 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
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| Antibiotic Therapy: Concepts I | Multidrug resistance; Therapeutic drug monitoring; Minimum inhibitory concentration (MIC); Time-dependent killing;
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| 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)
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| 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;
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| Antibiotic Therapy: Toxicities II | Monitor trough levels every 5 to 7 days; Monitor serum creatinine levels every 3 days
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| Aminoglycosides I | Gentamicin (Garamycin); kanamycin; neomycin (Neo-Fradin); streptomycin; tobramycin (Nebcin); amikacin (Amikin)
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| 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
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| Aminoglycosides: Indications | Gram -. Poorly absorbed through the GI tract. Given parenterally. (Exception: Neomycin. Given orally to decontaminate the GI tract before surgical procedures)
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| Aminoglycosides: Adverse Effects I | Cause serious toxicities. Nephrotoxicity: renal damage. Ototoxicity: auditory impairment and vestibular impairment. Must monitor drug levels to prevent toxicities
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| Aminoglycosides: Adverse Effects II | Ototoxicity and nephrotoxicity are the most significant. Headache, Paresthesia, Fever, Superinfections, Vertigo, Skin rash, Dizziness
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| Fluoroquinolones I | ciprofloxacin (Cipro), norfloxacin (Noroxin), levofloxacin (Levaquin), gatifloxacin (Tequin), moxifloxacin (Avelox), gemifloxacin (Factive)
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| Fluoroquinolones II | Excellent oral absorption
Absorption reduced by antacids
Effective against Gram - organisms and some Gram + organisms
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| Fluoroquinolones: Mechanism of Action | Bactericidal. Alter bacterial DNA, causing death. Do not affect human DNA
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| Fluoroquinolones: Indications | Gram - bacteria such as pseudomonas. Respiratory infections. Bone and joint infections. GI infections. Skin infections. STDs. Anthrax
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| Fluoroquinolones: Adverse Effects I | Headache, dizziness, fatigue, depression, restlessness, insomnia. n/v, runs, constipation, thrush, increased liver function.
Prolonged QT interval
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| Fluoroquinolones: Adverse Effects II | Rash, pruritus, urticaria, flushing, photosensitivity. Fever, chills, blurred vision, tinnitus.
Black box warning: increased risk of tendonitis and tendon rupture
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| Other Antibiotics I | clindamycin (Cleocin); linezolid (Zyvox); metronidazole (Flagyl); nitrofurantoin (Macrodantin); quinupristin and Dalfopristin (Synercid); daptomycin (Cubicin); vancomycin (Vancocin); colistimethate (Coly-mycin)
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| Other Antibiotics: Clindamycin | Used for chronic bone infections, GU infections, intraabdominal infections. May cause pseudomembranous colitis.
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| 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
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| Other Antibiotics: Metronidazole | Used for anaerobic organisms. Intraabdominal and gynecologic infections. Protozoal infections.
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| 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
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| Other Antibiotics: Quinupristin & Dalfopristin | Used for bacteremia and infections caused by vancomycin-resistant Enterococcus (VRE) and other skin infections. May cause arthralgias, myalgias
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| Other Antibiotics: Daptomycin | New class: lipopeptide. Used to treat complicated skin and soft-tissue infections
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| 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
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| 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.
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| Therapeutic | Decrease in specific signs and symptoms of infection are noted
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| Subtherapeutic | Signs and symptoms do not improve
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| Bactericidal | Kill bacteria
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| Bacteriostatic | Inhibit growth of susceptible bacteria (eventually leads to bacterial death)
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| Sulfonamides: Adverse affects I | Blood Hemolytic and aplastic anemia, agranulocytosis, thrombocytopenia, photosensitivity, exfoliative dermatitis, Stevens-Johnson syndrome, epidermal necrolysis,
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| Sulfonamides: Adverse affects II | n/v, runs, pancreatitis, crystalluria, toxic nephrosis, headache, peripheral neuritis, urticaria
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| Beta-Lactam Antibiotics | Gram -. (Penicillins, cephalosporins, carbapenems, monobactams, beta-latam ring)
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| Sulfonamides | Sulfadiazine
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| Sulfonamides | Sulfamethoxazole
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| Sulfonamides | Sulfisoxazole
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| Sulfonamides | Bactrim (Sulfamethoxazole + trimethoprim)
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| Cephalosporins | cefadroxil
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| Cephalosporins | cephradine
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| Cephalosporins | cefazolin
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| Cephalosporins | cephalexin
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| Cephalosporins | Cefazolin
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| Cephalosporins | Cephalexin
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| Cephalosporins | Cefoxitin (Mefoxin
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| Cephalosporins | Cefuroxime
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| Cephalosporins | Ceftriaxone (Rocephin)
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| Cephalosporins | Ceftazidime (Ceptaz)
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| Cephalosporins | Cefepime (Maxipime)
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| Carbapenems | Imipenem/Cilastatin (Primaxin)
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| Monobactams | Aztreonam (Azactam)
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| Macrolides | Erythromycin (E-mycin, E.E.S)
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| Macrolides | azithromycin (Zithromax)
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| Macrolides | clarithromycin (Biaxin)
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| Macrolides | dirithromycin
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| Ketolide | Telithromycin (Ketek)
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| Tetracyclines | Demeclocycline (Declomycin)
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| Tetracyclines | oxytetracycline
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| Tetracyclines | tetracycline
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| Tetracyclines | doxycycline (Doryx, Vibramycin)
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| Tetracyclines | minocycline
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| Tetracyclines | tigecycline (Tygacil)
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| Aminoglycosides | Gentamicin (Garamycin)
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| Aminoglycosides | kanamycin
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| Aminoglycosides | neomycin (Neo-Fradin)
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| Aminoglycosides | streptomycin
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| Aminoglycosides | tobramycin (Nebcin)
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| Aminoglycosides | amikacin (Amikin)
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| Fluoroquinolones | ciprofloxacin (Cipro)
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| Fluoroquinolones | norfloxacin (Noroxin)
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| Fluoroquinolones | levofloxacin (Levaquin)
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| Fluoroquinolones | gatifloxacin (Tequin)
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| Fluoroquinolones | moxifloxacin (Avelox)
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| Fluoroquinolones | gemifloxacin (Factive)
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