Antibiotics / Antimicrobial or Anti-infective Medications

General Information:

Factors affecting antibiotic effectiveness:

o Age infants and older adult are vulnerable to drug
toxicity due to a decreased rate of drug metabolism
and excretion
o For success of antimicrobial therapy - need healthy
immune system with antibiotics because antibiotics
do not cure they work with the hosts immune
system to fight infection
When infection is possible (i.e. elevated temperature,
purulent drainage), effective therapy requires that identify
organism and identify drug sensitivity: Procedure:
o Remove potential source of infection i.e. IV catheter,
arterial line, Foley, ETT possibly send for culture
o Draw exudates (throat, wound drainage) and body
fluids (blood, urine) for culture prior to initiation of
antibiotic treatment because antibiotics can suppress
microbial growth in cultures
o Treat with broad spectrum and quickly change to
narrow spectrum when organism is known because
broad spectrum kills off more competing(normal flora)
organisms than narrow
o Inappropriate use (especially broad spectrum) leads
to drug resistance
o Always check compatibility with other antibiotics and
meds when giving IV because may interact in IV
tubing

General patient teaching for all types of antiinfectives:

o Notify healthcare provider if symptoms of infection
persist or become worse
o Complete the full course of medications at prescribed
intervals otherwise drug resistance can develop
o Consult with healthcare provider before taking OTC
products.
o Stop medication and notify healthcare provider if the
following occur:
Hypersensitivity
o wheezing, hives, rash, shortness of
breath, itching, swelling of face or
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hands.
o Report super infection from overgrowth in mouth,
pharynx, vagina or bowel:
o Candida albacans (fungi) yeast
(monilial vaginitis)
o clostridium difficile
Symptoms include :
o vaginal or anal itching or discharge
o white (thrush) or black furry
overgrowth or coating on tongue can cause stomatitis
o Antibiotic Associated
Pseudomembranous Colitis (AAPMC)
from overgrowth of clostridium
difficile due to suppression of norm
gut flora - characterized by profuse,
loose (watery) or fowl smelling
diarrhea (10-20 stools per dayoften contains blood, pus and/or
mucus), abdominal pain, fever,
RX:
o treat with Flagyl (first) or
Vancomycin PO diarrhea usually
ceases 3-5 days after the stating of
treatment
o vigorous fluids and electrolyte
replacement
o instruct patient to notify healthcare
provider if have diarrhea Must
report more that 5 water stools per
day
o do not give drugs that decrease
bowel motility (antidiarrheals,
opioids, Anticholinergics) may
worsen the symptoms watery,
mucous, bloody stools (black tarry
stools)
o To maintain normal intestinal and vaginal flora,
consume products with live cultures (Probiotics lactobacillus acidophilus) that suppress disease
causing organisms. Probiotics are protective
bacterium (flora) that is normally found in the GI tract
and vagina. Normal flora is destroyed by antibiotic
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therapy. Examples of Probiotics are:

Bacid or Kefir capsules of lactobacillus
Lactobacillus Acidophilus found in
yogurt
o Frozen yogurt contains no live
cultures
o Keep in refrigerator
o

Capsules or granules

PENCILLINS (PCN)
o also called beta- lactam antibiotics
o considered very safe least toxic of all antibiotics
o kills wide variety of gram + and gram - organisms
Indications:
Respiratory: Strep Pharyngitis (strep throat), Pneumococcal
pneumonia,
o skin, soft tissue, GI, GU infections.
o prevention of endocarditis before dental surgery
Types:
o

o
o
o
o
Side
o

Pencillin G
narrow spectrum penicillins
Penicillin V
Penicillinase-Resistant Penicillins penicillinase is produced by
staphlycocci to inactivate penicillins therefore some penicillins are
ineffective i.e. naficillin, oxacillin.
Broad Spectrum (Aminopenicillins) [Ampicillin (omnipen), Amoxicillin
(Amoxil)]
Broad spectrum penicillins
Effects:
allergic reaction (1-10%) is main SE rash, pruritis, wheezing to
anaphylactic reaction (small percentage of anaphylactic reaction
observe for 30 minutes after injection or IV until the risk of
anaphylactic reaction has passed
three types of allergic reactions immediate 2-30 minutes,
accelerated 1-72 hours, late days to weeks
epinephrine or antihistamine to treat anaphylaxis ( IM, SQ or IV)
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o
o
o
o
o
o
o
o

use cautiously in renal disease because most are rapidly excreted by

kidneys:
Probenecid decreases renal excretion and increases blood level
of PCN
take with a full glass of water
reduce dose in renal disease
take each dose at even intervals complete full course.
Discard liquid form after 2 weeks
do not take PO with orange juice or other acidic fluids (may destroy
drug)
IM route can cause pain at injection site
Will inactivate aminoglycoside. Do not give in same IV tubing.
Seizures in high doses
Pseudomembranous Colitis, Superinfection (see above - general
information about anti-infectives)
advise patients using oral contraceptives to use an alternate form of
birth control
5- 10% have cross sensitivity (allergy) to cephalosporin
vancomycin, erythromycin, cephalosporins, tetracycline, and
macrolides are alternative for PCN allergies

CEPHALOSPORINS
Broad spectrum- skin respiratory UTI, Otitis Media, gram + and gram
infections and for patients who cannot tolerate PCN
o Used as an alternative to penicillin to treat infections
Types/ Indications:
o

Grouped into four generations based on their order of introduction into

clinical use. The higher the generation, the more effective. Third and
fourth generation can penetrate CSF i.e. bacterial meningitis
1. First generation: better against gram + than gram - Staph
and strep
Used widely for surgical prophylaxis
Ancef and Kefzol (Cefazolin) surgical prophylaxis
IM, IV (absorbed well after IM or IV). Steven Johnson
Syndrome
Keflex (Cephalexin) haemophilus influenza, otitis
media, sinusitis PO- full or empty stomach.
Absorbed well from GI tract
Second generation: more active against some gram infections - broader spectrum that 1st generation Used for
pneumonia, abdominal and pelvic infections
o Mefoxin (Cefoxitin) IM, IV
o Ceftin, Zinacef (Cefuroxime) PO, IM, IV
2. Third generation: spectrum against gram is extended
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longer acting than 2nd generation e.g. gonorrhea, salmonella

o Rocephin (Ceftriaxone) IM, IV
o Claforan (Cefotaxime) IM, IV crosses CNS used for
meningitis
3. Fourth generation: greater spectrum of antimicrobial activity
effective against organisms that are resistant to other
cephalosporins
o Maxipine (Cefepime) cross CNS
Side Effects:
o
o

o
o
o

o
o
o
o

PO N, V, diarrhea
Can be used for patients who cannot tolerate PCN however, has cross
sensitivity with Penicillins therefore, cephalosporins should not be
given to patients with a history of severe allergic reactions
(anaphylactic reaction) to penicillins - Mild reactions to penicillins
can use cephalosporins. Assess for allergy to PCN
Hypersensativity reactions are the most frequent maculopapular
rash/urticaria can develop several days after the onset of treatment is most common. instruct patient to report any signs of allergy i.e
rash, itching, hives
Excreted through the kidneys may be nephrotoxic, check - UO,,
BUN, creatinine
Metabolized in liver possible hepatotoxic
thrombophlebitis and pain at injection site minimize by rotating
sites, and administering slowly i, deep IM injections into a large
muscle / Use lidocaine to minimize pain, check site for tenderness or
redness - and notify the MD
will cause an antabuse reaction with alcohol (vomiting,
weakness, blurred vision)
Pseudomembranous Colitis, Superinfection (
Seizures
May reduce prothrombin levels, thrombocytopenia, neutropenia,
agranulocytosis

BACTERIOSTATIC INHIBITORS
suppress bacterial growth but do not kill bacteria, therefore are
second-line agents primarily because of emerging resistance or
toxicity.
Types:
o

1. TETRACYCLINES (i.e. Doxycycline (Vibramycin)

o Broad spectrum gram and gram +

o Use as a substitute in PCN allergic patients not first line drug choice
Indications:
o

For H. Pylori (with metronidazole and bismuth), travelers diarrhea,

anthrax, acne, periodontal disease, Lymes disease, Chlamydia
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Mycoplasma, malaria prophylaxis

Side Effects:
o

Interferes with absorption:

o Not administered with Mg and aluminum antacids, Ca
supplements, milk products, iron because they decrease
absorption. Must administer at least 2 hours before or 2 hours
after taking these meds.
o Administer anti-lipid meds at least 2 hours before or after

o
o

Rashes
Photosensitivity and increased sensitivity to sun- sunburn stay out of sun,
use sun block
Irritation of GI cramps, burning, esophagitis, diarrhea, nausea, vomitingmay give with food or milk but may decrease absorption. As a general rule
give on an empty stomach- 1 hour before and 2 hours after meals
especially dairy products. Take with 1 full glass of water 1 hour before bed
to prevent esophageal ulceration.

May cause Pseudomembranous Colitis and Superinfections (see

above - general information about anti-infectives)

Binds to calcium in teeth - yellow or brown staining of teeth, softening of

teeth - 4 months to 8 years(early childhood) when tooth enamel forms- also
can stain fetus baby teeth if mother take during pregnancy (prenatally) . Do not give during pregnancy or to children under 8 yrs.
Can depress bone growth
Excreted by the kidney and liver do not give in renal or liver failurecaution with insufficiency- can be hepatotoxic, pancreatitis,or nephrotoxic
Advise use of alternate form of birth control if using oral contraceptives
Decreases effectiveness of cephalosporins should not be given
concurrently.
Phlebitis at Iv site
Do not take expired medication may be toxic

o
o
o
o
o
o

2. MACROLIDES
o

Broad spectrum

Indications:
o
o
o
o
o

Respiratory tract - whooping cough (Pertussis), Legionnaires disease,

Mycoplasma pneumonia
H. Pylori
syphyllis
Skin/soft tissue infections caused by strep and staph
Used as alternate for PCN allergies

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Types:
1) Dirithromycin
2) Erythromycin (Emycin)
Used for Chlamydia
PO, IV (PO variable absorption from GI tract)
Side Effects:

Ventricular arrhythmias may exacerbate existing heart disorders

thrombophlebitis, very irritating to vein use large amount of IV
fluid give slowly
empty stomach with a full glass of water - food decreases
absorption but can be given with food if GI irritation occurs.
Enteric coated tablets are available
Pseudomembranous Colitis and Superinfection (- especially with
PO Emycin
GI are most common SE N,V, diarrhea, abdominal cramping
Distorted taste
Notify healthcare provider before taking OTC or herbal products.
Primarily excreted in the liver. May be liver toxic Hepatitis check enzymes, report yellow color of skin or eyes, dark urine,
pale stools
Many drug interactions:
o i.e.coumadin (wafarin), theophylline, carbamepezine can
increase levels
may exacerbate existing heart disorders.

3) Biaxin (Clarithromycin)
Used for: respiratory tract infection, Otitis Media, skin infections
Increased absorption with food 50% absorbed by oral route
Does not cause as much nausea as with E mycin
May Cause:
Steven Johnson Syndrome /Pseudomembranous
Colitis, /Epistaxis .
4) Zithromax (Azithromycin)
Do not give with meals decreased absorption
Less gastric irritation
Photosensitivity
4 day dose for respiratory, (OM) otitis media, skin

3. CLINDAMYCIN (CLEOCIN)
o Used for abdominal and pelvic (GYN) infections, septicemia
Side Effects:
o

rashes, bitter taste, dizziness, headache

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o
o
o

Pseudomembranous Colitis, Superinfection (see above - general

information about anti-infectives)
Use has declined because can promote severe, toxic antibiotic
associated pseudomembranous colitis (AAPMC)
Give with a full glass of water, with or without meals.

OXAZOLIDINONES
1) Linezolid (Zyvox)
To treat MRSA and VRE (vancomycin resistant enterococci)
PO rapid and 100% absorbed with or without food
VRE treatment 14-28 days
MRSA 10-14 days
Side Effects:
SE are: diarrhea, N, headache, pseudomembranous colitis (AAPMC),
hypertension with MAO inhibitors or tyramine containing food avoid
foods containing tyramine because of monoamine oxidase inhibitory
properties ( aged cheese, soy sauce, tap beers, caffeine beverages,
bananas, yogurt, chocolate)
Should do weekly blood counts because can cause anemia,
leukopenia and thrombocytopenia
Lactic acidosis periodic checks of bicarb levels
Peripheral neuropathy
Visual impairment
2) Teicoplanin- Targocid
o Used for: MRSA, osteomylitis, endocarditis
Side Effects:
o
o
o
o
o

Very few side effects

Ototoxicity
Pseudomembranous colitis
Hypertension in those taking MAO Inhibitors or tyramine containing food
- avoid foods containing tyramine because of monoamine oxidase
inhibitory properties ( aged cheese, soy sauce, tap beers,
Thrombocytopenia - monitor for bleeding

SULFONAMIDES
o
o

Broad spectrum
Primarily used to treat Ulcerative colitis, UTI, Malaria, OM, Chronic
Bronchitis
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o
o

Excreted primarily by kidneys encourage adequate hydration to

minimize damage at least 3000 ml per day if heart and kidneys can
tolerate.
Side effects
Skin rash- should discontinue if develop any type of rash,
photosensitivity
vomiting, nausea should be taken on an empty stomach with a
full glass of water
blood dyscrasias - hemolytic anemia, leukopenia ,
agranulocytosis, thrombocytopenia monitor labs
renal injury excreted by kidney, crystaluria, monitor urine
output, BUN, cr. encourage fluids at least 3000ml per day
1) Sulfamethoxazole (Gantanol)/UTI
2) Silver sulfadiazine (Silvadene)/Topical - Used for second and third
degree burns prevents colonization
3) Trimethoprin-Sulfemethoxazole (TMP-SMZ) (Bactrim, Septra)/Otitis
media, bronchitis, UTI, Protozoal infections /Can intensify the effects of
oral hypoglycemic. Phenytoin, Warfarin)
4) Sulfasalazine (azulfadine )Used to treat ulcerative colitis and Crohns
disease - not used as antibacterial drug - Used for its anti-inflammatory
effects

AMINOGLYCOSIDES
o
o

o
o

narrow spectrum used to treat serious infections caused by gram

organisms (i.e nosocomial (hospital acquired), E. Coli, Klebsiella) Very
toxic
Can cause:
o serious injury to inner ear - ototoxicity (damage to 8 th cranial
nerve) sx: decreased hearing, headache, tinnitus- ringing in
ears, dizziness (vertigo), ataxia, hearing loss, deafness - is
irreversible
o Nephrotoxic most serious SE kidney (potentially reversible) check BUN and Cr. Asses for proteinuria, oliguria or anuria, rapid
weight gain. Reduce dose with renal insufficiency. Increase fluids
if kidneys are functioning. Monitor I & O
o Superinfection AAPMC, vaginal discharge, stomatitis, glossitis
teach to report signs of redness, tenderness, white discharge,
white / black coated tongue, diarrhea, vaginal discharge
Must assess the trough (immediately before next dose) and Peak (30
minutes after IV or IM dose ) levels of drug to make sure they are not too
high and to adjust dose to therapeutic level.
Types of aminoglycosides:
o Gentamycin (Garamycin) tobramycin (TOBI, Nebcin) Amikacin
Least susceptible to organism resistance
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Neomycin sulfate Pre-op for GI surgery

FLOUROQUINOLONES
o
o

narrow spectrum (gram and some gram +)

Use for serious infections - Anthrax, UTI, URI, bones and soft tissue

o
o

Can give only once or twice daily increasing patient compliance

Do not give with multivitamins or minerals.

Contraindicated < 18 yrs of age-due to possible tendon rupture

(Achilles) discontinue if tendon pain occurs.
SE GI N,V, diarrhea, candida infection of pharynx and vagina
Excreted mainly by kidneys crystaluria irritates kidneys - drink at
least 8 glasses of water a day
Photosensitivity wear protective sunscreen and avoid exposure

May cause:

o
o
o
o
o
o

Seizures especially with epilepsy alcoholism avoid driving

Increase effect of Coumadin
Do not give with multivitamins or minerals

Types:
o Ciprofloxacin (Cipro)
o Levofloxacin (Levaquin)

CARBAPENEMS
o
o
o
o
o
o

Very broad spectrum Bactericidal used to treat mixed infections.

Penetrates CSF
Given for intra-abdominal infections
Do not mix with other medications or with DEXTROSE
Minimal SE GI (N,V, diarrhea), allergic reaction - rash, headaches,
paresthesias, small risk of seizures.
Types:
o Imipenem (Primacin)
o Meropenem (Merrem)

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I VANCOCIN (VANCOMYCIN)
o inhibits bacterial wall synthesis
o used only for severe infections
Used for:
Primarily for antibiotic associated pseudomembranous colitis
(AAPMC) _ caused by C. Difficile (use oral form of med) use
Flagyl (metronidazole) first because of the possibility of resistance
to vancomycin
o serious infections i.e. MRSA (methicillin resistant staph aureus) Staph organisms resistant to penicillinase (penicillinase is
produced by staphlycocci to inactivate penicillins). Because of
increased use, VRE is developing in critical care areas
o Not absorbed from the GI tract therefore PO only given for
infections of the intestines - antibiotic-related
pseudomembranous colitis (cause by C. difficile).
o severe PCN allergy - No cross sensitivity to PCN
o Can cause:
o Rapid infusion can cause Red Man Syndrome: hypotension,
tachycardia, flushing and rashes from histamine release - Infuse
slowly over 60 minutes or more to avoid this syndrome
o Ototoxicity the most serious side effect. Can be reversible but
can be permanent. Teach patient to report ringing in ears
(tinnitus) Check hearing before and during treatment.
o IV form can cause Nephrotoxicity- Excreted by the kidney
reduce dose in renal impairment monitor urine output, BUN, cr.
(note: PO form is not absorbed by GI tract see above)
o Check renal and hearing before start of therapy.
o Because PO vancomycin is not absorbed from the GI tract, there
is no need to decrease oral doses in patient with renal impairment
o Thrombophlebitis is common. Can cause necrosis prevent by
infusing in a dilute solution and changing IV sites frequently.
Check IV site
o Pseudomembranous Colitis, Superinfection (see above - general
information about anti-infectives)
o Serum Peak and Trough drug levels should be drawn: PEAK 30
minutes after completion of infusion. TROUGH - 1.5 to 2.5 hours
after completing the IV infusion.
METRONIDAZOLE (FLAGYL)
o

o
o
o
o
o

effective against protozoal infections, anaerobic bacteria (such as

Clostridium Difficile)
With C. difficile used Flagyl first before Vancomycin
Prophylaxis in surgical procedures, colorectal surgery and
intraabdominal infections
Crohns disease not Ulcerative Colitis
Used in combination with tetracycline and bismuth subsalicylate for
H. Pylori
o SE: severe reaction with alcohol flush, tachycardia, nausea,
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o
o
o
o

vomiting do not drink alcohol

metallic taste in mouth and dry mouth frequent mouth care
darkening of urine red brown color
Headache, dizziness and seizures

Pseudomembranous Colitis, Superinfection (see above - general

information about anti-infectives)
Do not refrigerate IV can precipitate , infuse over 1 hour

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